The role of the contemporary cardiac nurse

Noa Avissar-Caspi
RN MPH

Ossnat Broshi-Chen MA

Ghasan Salameh
RN MA

Daud Latif RN BA

Dina Granot RN MA

Yonathan Hasin MD
Baruch Padeh Medical Centre
Poriya, Israel

The progress made in the management of cardiac patients over  the years has demanded a parallel nursing specialty. Cardiac  nurses are treating patients hospitalised in intensive  cardiac care units (ICCUs), catheterisation laboratories,  intermediate units and cardiology wards. Cardiac nurses are  also needed in ambulatory services, including cardiac  outpatient clinics (especially for heart failure services)  and noninvasive cardiac laboratories – mainly during  pharmacological stress testing and trans­oesophageal  echocardiography (ECG). In addition, the cardiac nurse has  an active role in the clinical research conducted in the  department and in guiding nursing students.

An ever-expanding role
In the cath lab and ICCU the nurse mainly focuses on the  acute stage of the disease with the purpose of saving life.  The nurse needs to be skilled in advanced cardiac life  support, be familiar with the prompt IV administration of  lifesaving drugs and how to monitor their effect, know and  support the interventional technology used and treat complex patients who suffer from multisystem disease states that demand special intensive care. On the general cardiology ward the nurse should be familiar with and treat a variety of health conditions such as atherosclerosis, heart failure and rhythm disorders. The nurse must know the ward’s prevalent diseases, treatment goals, monitoring and evaluation, the relevant drugs and the recommendations for  secondary prevention of the disease. The nurse should  monitor patients following various procedures. The main procedures are cardiac catheterisation and intervention, invasive electrophysiology study and treatment, and pacemaker/defibrillator implantation. Monitoring must be  very strict, along with a proper explanation to the patient  before and after the procedure, a precise follow-up and  postprocedure records.(1,2)

The nurse is expected to treat the patient holistically,  taking care of the different needs of both patients and  their families. During hospitalisation the nurse should help  patients to achieve a quick recuperation and secondary  prevention of disease progression by employing programmes that include an explanation on the disease itself, its risk factors and guidance for discharge, including proper activity, diet and medications prescribed. The hospital is an outstanding arena to begin secondary prevention since it provides a proper psychological care combined with the availability of multiprofessional staff. The nurse is at the core of this structure and is responsible for summoning and coordinating the carers involved. Incorporating a multidisciplinary staff (eg, dietitians, physiotherapists, social workers) should provide the patient with proper knowledge both during hospitalisation and towards discharge.(3,4)

Special attention should be paid to continuation of  treatment upon return to the community, and the nurse should  be familiar with community resources (welfare,  rehabilitation, health maintenance organisations: HMOs) and  address the patient accordingly. Such attention and  familiarity contributes to the efficiency of provided medical care and to decreased rehospitalisation. It is recommended to conduct a routine follow-up by phone to discharged patients, as it may encourage better cooperation and compliance as well as supplying moral support.

The ever-expanding and demanding role of the cardiac nurse indicates the need for continued education in addition to the basic requirement of being an officially certified nurse. Updating new therapeutic attitudes and medications should be conducted both individually and institutionally and include updates by medical staff, nursing journals and  academic courses.(3,4,5)

Treatment and monitoring of common diseases
Angina pectoris
Ischaemic chest pain occurs when blood supply fails to meet myocardial oxygen demand. The diagnosis is based on the medical history, clinical manifestations, dynamic ECG  changes during pain and the response to acute treatment. The physiological treatment rationale includes decreasing  myocardial oxygen demand and increasing oxygen supply. This can be achieved by the use of medications and by balancing risk factors. Ultimately, coronary revascularisation is to be considered. Pharmacotherapy for angina pectoris is divided into four types: anticoagulants, nitrates,  beta-blockers and calcium channel blockers.

Nursing supervision should include meticulous monitoring of  the patient, including pain intensity, vital signs and ECG  during and following pain episodes, follow-up of laboratory  results, anxiety management and proper explanation of the  condition. Patients should be instructed on the best way to
exercise, diet, stop smoking, lose weight and reduce stress. The nurse should provide proper instructions on management of chest pain episodes – the use of sublingual nitrates, high-posture resting and call for help for prolonged episodes.(1,6)

Acute myocardial infarction
When blood supply is impaired for a long period of time it  results in myocardial damage. The symptoms are prolonged and  pronounced, and the risk of complications (eg, rhythm  disturbances and acute heart failure) is increased. Patients  are hospitalised in the ICCU and considered for prompt or  early revascularisation while receiving medical therapy  aimed at proper anticoagulant, haemodynamic and metabolic  control.(1,6) The goals of nursing intervention are to  assist in treatment aimed at reperfusion (thrombolysis or  primary PCI); monitor and treat arrhythmias, haemodynamic  status and respiratory status; maintain proper fluid and  metabolic balance; administer proper medications; and  support the patient and family.

Drug therapy includes anticoagulants, antiplatelet  aggregants and load reduction medications. As some patients  are prone to bleeding, the nurse should check routinely for  any complications, especially at the puncture sites.  Life-threatening dysrhythmias and haemodynamic imbalance  should be solved immediately. Supporting the patient and  family, especially in the face of obvious life-threatening  conditions, is extremely important.

Heart failure
Patients may be hospitalised because of gradual  deterioration in congestive heart failure (CHF), acute  decompensation in chronic stable CHF or acute heart failure  syndrome. The most common reason for heart failure syndrome is damage to the heart muscle induced by coronary artery disease. The risk of developing heart failure can be decreased by proper medical care. Qualified cardiac nurses can provide beneficial treatment for heart failure in all  that is related to shortening the hospitalisation duration, preventing further hospitalisations, reducing costs and preventing death. The contribution of the cardiac nurse is crucial to the successful functioning of any heart failure unit.(7)

Nursing intervention should include monitoring the vital  signs (eg, fever, pulse and blood pressure), weight and  fluid balance and follow-up of laboratory results –  especially for kidney function and electrolytes, glucose  level, liver function and blood count.

Pharmacotherapy plays a major part in treating heart  failure. The nurse should be familiar with the available  pharmacotherapy and its use. In the acute syndrome this is  composed mainly of diuretics, vasodilatation (especially  nitrates) and positive inotropy (only if absolutely  mandatory). In chronic cases pharmacotherapy is comprised mainly of beta-blockers, ACE inhibitors, angiotensin- receptor blockers and aldosterone blockers (all shown to improve longevity), as well as diuretics, nitrates and cardiac glycosides, which may help to improve symptoms. Nurses have a major role in identifying patient habits that need to be changed. Guiding the patient through the disease is all part of the treatment.(1,6,8)
 
Preparation and follow-up peri-interventional procedures
Cardiology department staff should prepare the patient for  the procedure, including baseline blood tests, ECG, fasting,  fluid transfusion, preprocedure medication and appropriate  dress. Special attention should be given to patients prone  to complications during and following the procedure, particularly those who are prone to renal failure, are sensitive to contrast medium, have severe unstable  coronary syndrome, have unstable haemodynamic condition and those who are very elderly. On returning to the ward, the patient is then wired to a monitor and a nurse should check the blood pressure, heart rate and rhythm, the area of the percutaneous incision, peripheral pulse, leg skin  temperature and colour, and urine output. In the first 24  hours there should be good hydration to facilitate secretion  of the contrast medium. Postcoronary revascularisation,  patients are given anticoagulant and/or antiplatelets.(1,6)

The role of the cath lab nurse
The purpose of the cath laboratory is to perform  haemodynamic and angiographic evaluation of the heart and  its coronary arteries, and to apply various percutaneous  interventional techniques to improve the pathology. Electrophysiological procedures include electrical mapping of the heart, induction and interruption of cardiac  arrhythmias, localised ablation of the source of arrhythmias  and implantation of various electrical devices (eg,  pacemakers and defibrillators).

The cath lab nurse is expected to take care of the patient  and assist the physician in performing the procedure. Upon  arrival the nurse admits the patient, gives sedative  medications, shaves the area of the puncture site and  prepares the patient on the table. During the procedure  there should be a constant watch over vital signs, oxygen  supply and anxiety management. It is also advised to keep in close contact with the patient’s family by providing updates and other relevant information.

The nurse is involved in all aspects of the treatment,  including technical assistance and introduction of  medications as required, and should be ready to participate  in any emergency treatment that becomes necessary during the procedure (eg, cardiopulmonary resuscitation). 

Vital signs are continuously monitored postprocedure, with  particular attention paid to possible chest pain and comfort  while lying down (especially passing urine). A full  explanation should be given to both patient and family.  Twelve-lead ECG will be performed and the introducer taken  out with proper haemostatic care. The nurse will give the  proper medication prescribed. After stabilisation the  patient will be transferred to either the cardiology  department or the ICCU.

The ICCU nurse
Most patients in the ICCU suffer from acute coronary  syndromes. Others suffer from severe rhythm disorders, acute  heart failure or catheterisation complications.(8) The task  of the ICCU staff is focused on saving life and treating  complex cardiorespiratory conditions. The nurse is expected  to graduate a special intensive care course followed by  continued updating in all aspects of acute cardiac  care.(9,10)

The ICCU nursing team is the backbone of the unit. The ICCU nurse is required to be familiar with and able to handle the highly sophisticated and complex monitoring system with its central station as well as the ancillary equipment, including respirators, pacemakers, intra-aortic balloon pumping and ultrafiltration. The nurse has to be intimately familiar with the 12-lead ECG, the precise diagnosis of cardiac arrhythmias and invasive haemodynamics, including arterial lines, central venous pressure and pulmonary artery catheters. The ICCU nurse is the first to respond to any change in the patient’s conditions and, if signs are critical, is expected to initiate treatment, such as nitroglycerin for acute chest pain with ECG changes, DC shock for ventricular fibrillation and IV atropine/adrenalin for cardiac arrest.

Conclusion
The contemporary cardiac nurse should present a variety of  skills and proficiencies. The nurse is standing at the heart  of the treatment and can be a full partner in the  decision-making process. Cardiac nurses are especially  important in the ICCU, cath lab stepdown unit and cardiology ward. They also contribute to ambulatory patient care in the noninvasive cardiac laboratory and outpatient clinic.

The cardiac nurse has a significant role in the response of  patients to the medical care and in preventing further  hospitalisations. The nurse must prioritise the guidance  aspect of her/his role in order to give comprehensive care.  Cooperation with other bodies within the community should  also be maintained for the benefit of the patients.

Constant learning, knowledge updating and integration in  medical research should be regarded as a major interest of  both the individual nurse as well as the hospital  establishment. A further evaluation of incorporating nurses  within medical research both for improving the quality of  care and increasing personal satisfaction should be  encouraged.

References

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