1. Can you Feel it? Karen George Clinical Nurse Advisor/Independent Providers

2. Overview of the session  Atrial Fibrillation  Early signs and symptoms of stroke and TIA  Theory of taking a pulse  Practical session on taking pulses  Recording findings when to refer

3. Karen George Clinical Nurse Advisor/Independent Providers

4. Learning Outcomes  Define Atrial Fibrillation (AF)  Understand the causes of AF  List some of the common symptoms  Recognise the complications associated with AF

5. Can You Feel it?  Atrial Fibrillation is the most common heart rhythm disturbance and affects up to 500,000 people in the UK  AF can affect adults of any age and becomes more common the older you get  In the over 75–year- old age group it affects about 10% of people  It accounts directly for over 96,000 hospital admissions per year  It consumes 1% of the NHS total budget  Left untreated AF can lead to serious complications such as heart failure and stroke

6. The Heart  The heart is a muscular organ that generally situated in the middle of the chest, slightly towards the left  Structurally, the heart consists of two sides, a right and left  The right side pumps the blood through the lungs to collect oxygen before travelling to the left side of the heart  From here it is pumped through the body. To return eventually to the right side once more  Both sides of the heart contract at the same time in a single coordinated action to produce a heart beat

7. What happens in AF?  When the heart beats normally, its muscular walls contract (tighten and squeeze) to force blood out and around the body. Then they relax, so that the heart can fill with blood again. This process is completed every time the heart beats  In AF, the upper chambers of the heart (the atria) contract randomly and sometimes so fast that the heart muscle cannot relax properly between contractions

8. What causes AF?  High blood pressure  Coronary heart disease  Mitral valve disease (caused by rheumatic heart disease, valve problems at birth, or infection)  Congenital heart disease (abnormality of the heart present since birth)  Pneumonia  Lung cancer  Pulmonary embolism  Overactive thyroid

9. Symptoms of AF  Palpitation  Tiredness  Shortness of breath  Dizziness  Chest pain (angina)  Low blood pressure  Heart failure  Some AF patients have no symptoms at all and it is only discovered at a routine medical examination

10. Complications of AF  When the atria (upper chambers of the heart) are not pumping efficiently, as in AF, there is a risk of blood clots forming  The blood clots may move into the ventricles (lower chambers of the heart) and get pumped into the lungs or the general blood circulation  Clots in the general circulation can block arteries in the brain, causing a stroke  The risk of stroke in people with AF is about double that of the general population

11. Complications of AF  However the risk depends on a number of factors, including:  Your age  Whether you have high BP  Heart failure  Diabetes  Previous history of embolism

12. Karen George Clinical Nurse Advisor/Independent Providers

13. Learning Outcomes  Define what a Stroke and TIA is  Understand the causes of a stroke/TIA  Recognise the signs and symptoms of a Stroke/TIA  Understand why recognition of the onset of signs and symptoms is essential  Justify the need to access emergency/urgent services for prompt assessment.  Understand F.A.S.T

14. Stroke/TIA causes and risk factors  High blood pressure  Cardiovascular disease  Diabetes  Age  Gender  Ethnic background  Genetic inheritance  Smoking  Unhealthy diet  Lack of exercise  Alcohol

15. What is a Stroke/TIA?  A stroke is an attack on the brain.  It happens when the blood supply to part of your brain is cut off.  For the brain to function, it needs a constant blood supply.  Which supplies vital nutrients and oxygen.  A stroke happens when the blood supply to part of the brain is cut off.  The brain cells die or are damaged.

16. Types of Stroke  There are two main types of stroke.  The most common type of stroke (about 80% of cases) is caused by a blockage. This is called an Ischaemic stroke and may be caused by:  cerebral thrombosis - when a blood clot (thrombus) forms in a main artery to the brain.  cerebral embolism - when a blockage forms in a blood vessel somewhere else in the body. Caused by a blood clot, air bubble or fat globule (embolism) and is carried in the bloodstream to the brain.

17. Types of Stroke  The second type of stroke is caused by a bleed (in about 20% of cases).  This is called a Haemorrhagic stroke and happens when a blood vessel bursts, causing bleeding (haemorrhage) in the brain. May be caused by: 1. intracerebral haemorrhage, when a blood vessel bursts within the brain. 2. subarachnoid haemorrhage, when a blood vessel on the surface of the brain bleeds into the area between the brain and the skull (subarachnoid space).

18. Transient ischaemic attack (TIA)  A Transient Ischaemic Attack (TIA) happens when your brain’s blood supply is interrupted for a very brief time. This is often called a mini-stroke.  It is an episode where some brain function is temporary lost due to a short lived disruption in the blood supply to the brain.  With a TIA, part of your brain goes without oxygen for just a few minutes.  A TIA is a sign that this part of your brain is not getting enough blood and that you may be at risk of a more serious stroke in the future.

19. What are the common symptoms of stroke?  Sudden, severe headache  Numbness, weakness or paralysis on one side of your body (signs of this may be a drooping arm, leg or lower eyelid, or a dribbling mouth)  Slurred speech or difficulty finding words or understanding speech  Sudden blurred vision or loss of sight  Confusion or unsteadiness

20. Recognition !

21. Karen George Clinical Nurse Advisor/Independent Providers

22. Can You Feel it? The opportunistic detection of Atrial Fibrillation (AF) to prevent the risk of stroke and other serious medical conditions associated with the presence of AF

23. Learning Outcomes  Understand how to detect a pulse  Identify /describe a regular pulse  Identify/ describe an irregular pulse  Demonstrate manual palpation of a radial pulse  Explain how to document your residents pulse readings  Identify what action to take when an irregular pulse is detected  Record outcome of action taken

24. What is your pulse?  When the heart beats blood is pushed out of the heart into the body causing a bulge in the arteries. This bulge of pressure is called a pulse, and the pulse can be felt anywhere an artery passes close to the skin.  The pulse indicates the heart rate and the heart rhythm. Being aware of your pulse is important because it may indicate an abnormal heart rate or rhythm. The pulse can be taken in several points on your body. Can you name two of the easiest places?

25. On the neck: below the earlobe between the muscle of the neck and the wind pipe (carotid pulse) On the wrist: between the end of the thumb and where a watch strap would rest (radial pulse)

26. Regular/Irregular Pulse  The pulse should be regular, i.e. the bulges caused by the heart beating occur with the same rhythmical timing.  Irregular pulse when palpated will not have the rhythmical timing of the regular pulse and therefore should be palpated for longer. Bom – bom – bom – bom – bom – Regular Bom – bom – bombom – bom –bombom - Irregular

27. Why it is important?  An irregular pulse strongly indicates that the heart is not beating in a uniformed way and moving the blood through its chambers swiftly, this can result in the blood flow becoming sluggish and lead to clots which can break loose and travel to the brain or to other parts of the body.  Can you think of things that can affect our pulse rate?

28. What Can affect your pulse rate?  Age  Medication  Caffeine  Level of fitness  Anxiety  Stress  Exercise

29. How to take a Pulse

30.  Using three fingers, place them on the inside of the wrist between the watch strap and the base of the thumb.  Keep firm pressure on the wrist with your fingers in order to feel the pulse.  The rate of the pulse can be found by counting for 60 seconds and multiplying by two, this can give the number of beats per minute  The heart rate naturally varies, depending on activity and time of day.  Normal pulse rate falls between 60 bpm and 100 bpm.

31.  To assess the resting pulse rate in your wrist, sit down for 5 mins beforehand. Remember that any stimulus taken before the reading will affect the rate. You will need a watch/clock with a second hand.  With your hand, place your index and middle fingers on your wrist at the base of your thumb. Your fingers should sit between the bone on the edge of your wrist and the stringy tendon attached to your thumb. Once you have found your pulse, keep firm pressure on your wrist with your fingers in order to feel your pulse Tendon Bone Pulse GROUP ACTIVITY

32.  Count for 30 seconds and multiply by 2 to get your heart rate in beats per minute. If your heart rhythm is irregular, you should count for 60 seconds and do not multiply.  Record your findings and follow the pathway. GROUP ACTIVITY

33. Pulse Check Pathway Weekly pulse checks or resident has a fall Pulse Regular If fall - assess and take appropriate action weekly pulse check and record Pulse Irregular If resident well refer to GP or OOH 12 Lead ECG If resident unwell 999

34.  karen.george@shropcom.nhs.uk karen.george@shropcom.nhs.uk Further Information: www.nice.org.uk www.heartrhythmcharity.org.uk www.bhf.org.uk