Ossnat Broshi-Chen MA
Daud Latif RN BA
Dina Granot RN MA
Yonathan Hasin MD
Baruch Padeh Medical Centre
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
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.
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.
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.
- Smeltzer SC, Bare BG. Brunner and Suddarth’s Textbook of medical surgical nursing. Philadelphia: Lipincott;1996.
- Quinn T. The role of nurses in improving emergency cardiac care. Nurs Stand 2005;19:41-8.
- Riley J, Brodie L, Shuldham C. Cardiac nursing: achieving competent practitioners. Eur J Cardiovasc Nurs 2005;4:15-21.
- Boyde M, Jen C, Henderson A, Winch S. A clinical development unit in cardiology: the way forward. Int J Nurs Pract 2005;11:134-9.
- Pelletier D, Duffield C, Adams A, et al. The cardiac nurse’s role: an Australian Delphi study perspective. Clin Nurse Spec 1997;11:255-63.
- Available from: www.escardio.org
- Stewart S, Horowitz JD. Home-based intervention in congestive heart failure: long-term implications on readmission and survival. Circulation 2002;105:2861-6.
- Svendsen A. Heart failure: an overview of consensus guidelines and nursing implications. Can J Cardiovasc Nurs 2003;13:30-4.
- Hasin Y, Danchin N, Filippatos GS, et al. Recommendation for the structure,organization and operation of intensive cardiac care units. Eur Heart J 2005;26;1676-82.
- Merkouris A, Papathanassoglou ED, Pistolas D, et al. Staffing and organization of nursing care in cardiac intensive care unit in Greece. Eur J Cardiovasc Nurs 2003;2:123-9.