- Email: [email protected]
The changing role of coronary care nurses
!ncmCkwand Critic&Can Nursing (1992) 8,82-93 0 Lmgman
GroupUK
Ltd 1992
The changing role of coronary care nurses Jane E. Caunt
The purpose in this article is to give an overview of the role of a coronary care nurse. No attempt is made to give a detailed account of any particular aspect of care but rather to inspire coronary care nurses to think about their practice and what can be achieved. In the 1960s Coronary Care Units (CCUs) were shown to reduce mortality from fatal arrhythmias and nursing care was based around observation and emergency treatment. The focus of coronary care is now moving towards infarct size reduction and the prevention of infarction in patients with unstable angina. Nurses are adapting their role accordingly - the skill, knowledge and judgement required to recognise reversible ischaemic episodes in the early pre- or post-infarctional period is paramount. It is equally and vitally important that nurses are able to recognise and assess the psychological and rehabilitation needs of patients. These aspects of care can be met ideally by using a system based on primary nursing and focusing on the patients’ individual needs. Nursing practice should be research-based, and under constant review with positive change encouraged.
INTRODUCTION Almost 30 years have elapsed since the advent of the first CCUs in the early 1960s. Before the introduction of intensive coronary care at least 30% of all patients admitted to hospital with acute myocardial infarction died during the period of hospitalisation. But with the introduction of a Coronary Care Unit, the mortality rate fell to around 15%, mainly due to the early detection and immediate treatment of life-
Jane E. Caunt RGN, ENB 124,112 Moor Lane, Newby, Scarborough,
North Yorkshire, Y012 5SP
(Requests for offprints to JCI Manuscript
82
accepted 75 February 7992
threatening arrythmias, which accounted for 47% of deaths (Meltzer, 1961). Most of the success of the system was attributed to the skillsof specially trained nurses who were able to interpret the electrocardiographic findings displayed on the cardiac monitors and recognise the significance of changes in cardiac rate and rhythm. They were able to assess the clinical condition of patients repeatedly by planned, careful observation in order to detect signs of the complications of myocardial infarction. Most importantly the reduction in mortality was due to nurses being able to assume a decision-making role in emergency situations and defibrillate patients immediately instead of awaiting the arrival of the medical team (Meltzer, 1962).
INTENSIVE
Even so, particularly in Britain, it took a long time for hospitals to recognise that their newly developed CCUs needed not only expensive monitoring and resuscitation equipment but the specially trained and highly skilled nurses to go with it; nurses with delegated authority to make and carry out therapeutic decisions based on their own observations and judgement. In practice this entails interpretation of arryhthmias, emergency defibrillation, administration of emergency intravenous drug therapy (Meltzer, 1962). More recent findings again support their view that to avoid delays in vital treatment all nurses, particularly those working in coronary care areas, should be trained to defibrillate and given the authority to do so. One study of local policies and procedures highlights the delays which can occur from onset of ventricular fibrillation to defibrillation whilst awaiting the arrival of a doctor. In this particular study in one hospital the mean time from a cardiac arrest to arrival of a doctor was 2 min and 23s. In this hospital the coronary care nurses were not given the authority to defibrillate. In contrast, in a hospital where coronary care nurses weregiven this authority, the average time from onset of an immediately life-threatening arrhythmia to treatment with the defibrillator was 26s, the shortest time being 12s and the longest 35s (Caunt, 1987). Even now, there are CCIJs in the United Kingdom where these basic components of coronary care nursing are not practised. Most practising coronary care nurses find such a situation inexcusable and feel that it is gross negligence of some nurse managers who appear to discourage such practice, and in some cases oppose it. Nowadays there are newer drugs to suppress arrhythmias, vasodilators, beta-blockers and angiotensin converting enzyme (ACE) inhibitors and, in the last few years, the use of thrombolytics and aspirin therapy has become routine in coronary care units and has reduced mortality rate by a further 25% (ISIS 2, 1988). Cardioversion and resuscitation techniques have improved. Temporary and permanent pacemaker support, angiography, angioscopy,
AND CRITICAL
CARE NURSING
83
angioplasty and surgical techniques are available. The greatest benefit in terms of mortality may eventually come from primary prevention, but information on secondary prevention with improved drug therapies, surgical techniques, angioplasty and cardiac rehabilitation also shows a reduction in both mortality and morbidity (Joy, 1989). Despite these improved figures, the need for acute coronary care will remain and there is presently a trend towards an increase in the number of admissions to CCUs due to:
1) an increased referral rate from general practitioners (GPs) of patients to receive urgent thrombolysis, who might otherwise have been left at home 2) an increasing number of elderly people who are living longer as a direct result of thrombolysis 3) extended life-saving skills of paramedic/ ambulance personnel resulting in more patients being delivered to hospital alive 4) an increased public awareness of the symp toms of a heart attack.
CORONARY CARE NURSING TODAY Good coronary care nursing is based upon general nursing principles, to help the patient maintain and regain as near normal a lifestyle as possible and perform daily activities. These nurses need to be competent in assessing the various needs of patients and their families to ensure the provision of physical safety comfort, and emotional support. Emotional support is vital to help each patient to overcome not only the illness itself but hospitalisation and therapy in an alien and technical environment which can be an anxiety-provoking, stressful experience (Jowett & Thompson, 1989). Each nurse must be able to assess and interpret the patients’ needs, set priorities, make judgements and take the necessary actions. It is only in addition to this that she/he needs to be skilled in technological advances. Most patients are totally
84
lNTENSlVEANDCRlTlCALCARENURSlNG
reliant on nursing support, whether being revived following cardiac arrest or in need of emotional support for themselves or their families. It is distressing to realise that without adequate training, experience and understandcare nurses can ing of their role, coronary become more skilled at technical and invasive manoeuvres than in recognising the need for them (Jowett & Thompson, 1989). With the advent of the English National Board 124 Coronary Care course and comprehensive teaching programmes within individual units, many nurses are highly skilled and committed to their work. Defibrillation, emergency intravenous drug therapy, recording and interpretation of electrocardiography have become normal practice in many coronary care units. Experienced coronary care nurses are probably more skilled and knowledgeable about these than many doctors, and yet these duties are still deemed part of an extended role and have to be officially delegated by doctors. If these skills are an accepted part of the CCU nurse’s role, should they be delegated by members of another profession? Or should nurses be talking about the need to expand the role of nurses officially and continue to provide suitable training within the Coronary Care Unit teaching programmes and ENB courses? This is not to say that doctors should not be involved in the teaching of nurses - this should be wholly welcomed - but should it be a requirement for certificates of competence to be signed by a doctor? (DHSS, 1989)
NURSE-DOCTOR RELATIONSHIP Both nursing and medical staff need to demonstrate interpersonal confidence and trust, with good communication and mutual support. The concept of coronary care nursing is based upon a team approach with the nurse and attending physician sharing the responsibility for patient care (Abdellah, 1972). Frequently their work overlaps, particularly in technical areas, but nurses must not lose sight of their role and become too opinionated where medical treatment is concerned. otherwise thev mav give the
impression of being anti-doctor, which is counter-productive and can cause a fractious working atmosphere (Jowett & Thompson, 1989).
PRIORITIES ON ADMISSION Admitting a patient to CCU involves a sequence of priorities, the final order of which is determined by the nurse. The critical factor in establishing priorities is the patient’s clinical condition and needs at the time of admission. Pain, fear and apprehension are almost invariably present in patients suffering evolving myocardial infarction. The pain of acute myocardial infarction is principally due to on-going ischaemia of viable but threatened myocardial tissue rather than necrosis. Conversely patients with the electrocardiographic signs of silent ischaemia or infarction may have impaired central responses to painful stimuli, therefore do not ‘feel’ the pain (Glazier et al, 1986). Proper evaluation and management of chest pain or its equivalent in patients with silent ischaemia/ infarction requires speed, skill and compassion. Oxygen and nitrates reduce the ischaemia (Kukin et al, 1990) but most patients require at least 5 mg of diamorphine intravenously together with an anti-emetic. This relieves the pain and anxiety and can reduce the risk of arrhythmias. Doses of less than 5 mg diamorphine are rarely effective in definitive myocardial infarction except in very frail small-framed individuals (Townsend, 1988). Large-framed patients may need larger initial doses, e.g. 1Omg. Marked respiratory depression following administration of opiates can occur in individuals unusually sensitive to their effects, or those with chronic airways disease, which highlights the need for patient’s assessment of each careful requirements. All coronary care nurses who administer diamorphine should be fully conversant with the indications, contraindications and side-effects of this drug (as with any other drug administered). The knowledge levels of some coronary care nurses about diamorphine and its effects are
INTENSIVE
clearly inadequate, as demonstrated by Willets’ study in 1989. She handed out 40 questionnaires to nurses working in the CCUs of two district hospitals. Although the nurses in the survey were well aware that effective pain control plays an important part in limiting infarction size, their actual knowledge of the effects of diamorphine was relatively very poor. For example only 4 1% knew that maximal respiratory depression is reached within 5 to 10min of intravenous injection and only 25% knew that diamorphine’s peak analgesic effect is reached within 20 min of intravenous administrations. The same study also highlights the fact that, in general, pain relief in CCUs is inadequate. 80% of patients in her survey said that their pain never really disappeared throughout their stay in the CCU, and 40% of these said that their anxiety about their condition was increased during this time. The traditional treatment of pain with nitrates and diamorphine given ‘when necessary’ (p.r.n.) needs to be reconsidered (Willetts, 1989). During recent years continuous infusions of nitrates have become fairly standard practice for some patients nursed in CCUs, as a treatment for ischaemic cardiac pain, silent ischaemia and control of left ventricular failure. It is vital that nurses know how to assess cardiac pain properly in order to differentiate it from the many other causes of chest pain and thereby administer appropriate analgesia. It is not uncommon for a patient with ‘unresolved chest pain’ 24 h or so after admission to be given an assortment of remedies, e.g., nitrates, paracetamol, gaviscon, as no-one is quite sure whether the pain is cardiac or not. Assessment is often hindered by the apparent inability of the patient to express the exact location and character of the pain. The continuation or recurrence of the pain in the hours or days after treatment has begun does not invariably mean clinical deterioration or extension of infarction. Often the pain is due to inflammatory processes manifesting as the clinical myopericarditis syndromes, and selection of optimum analgesic medication should move from potent narcotics given intravenously to orally-administered non-steroidal anti-
AND CRITICAL
CARE NURSING
85
inflammatory preparations, e.g. indomethacin (Kukin et al, 1990). In a CCU it is nurses who assess the effectiveness of analgesia and as patients’ advocates they should encourage doctors to prescribe adequate and appropriate analgesia. It is the nurses’ responsibility to get treatment reviewed if it is ineffective (Willetts, 1989). However it should be remembered that there are many variables which may influence the management of pain. These include the promotion of a calm, restful environment, the teaching of relaxation, the patients’ ability to carry this out and the ability of each patient to understand the reasons for his/her pain, and the importance of reporting it as it arises. Patients should be admitted rapidly as time is crucial. Up to 50% of patients who die within the first 28 days following a myocardial infarction do so within the first hour, commonly from arrhythmias which should be preventable with adequate monitoring. Thrombolytic drugs should be administered urgently to appropriate patients, as they are most effective when given as soon as possible after the onset of symptoms (ISIS 2, 1988). These drugs dissolve thrombus, namely the clot in the coronary artery which is causing the infarction, thereby restoring the blood supply to that area of myocardium. This minimises the damage and in some cases, if given early enough, reverses the process of the heart attack. The ISIS 2 (1988) study investigating the effectiveness of thrombolysis showed that in a number of nations including the UK only 24% of patients were admitted within 3 h of onset of symptoms. A similar Italian study (GISSI, 1986) showed that 52% of patients were admitted within 3 h of symptoms first occurring. Coronary care nurses can play a major role in educating patients regarding when to call an ambulance or contact a GP, should chest pain recur at home following hospital discharge. Records can be kept within CCUs of the time interval between ‘onset of acute symptoms’ and admission to CCU and possible sources of delay identified. Direct admission to CCU of patients referred by a GP, by-passing the Accident and Emergency
86
INTENSIVEANDCRITICALCARENURSING
Fii. 1 Reasons for delay Name 1. 2. 3. 4. 5.
Diagnosis
Time onset of symptoms Call to GP/Ambulance Arrival at A & E Arrival at CCU Time of thrombolytic -
Department, (A & E) has been shown to reduce delay. Also success in reducing delay has been possible where high risk patients with known coronary artery diseases have been advised to refer themselves to hospitals when necessary, without any increase in inappropriate referrals (Reynell, 1983). Despite the importance of early thrombolysis, unacceptable delays in initiating it still occur in hospital. In order to put this delay in perspective we undertook a small study of 49 patients in Scarborough District General Hospital to monitor the time lapse (Fig. 1). Until a decision was taken to try and reduce the time lapse from patients’ arrival at the hospital to initiation of thrombolysis the median time was 1 h 7 min shortest time was about 28 min. As a lot of the delays occurred with patients admitted via the A & E Department, we have since shown a need to alter the admission procedure there. Before the study patients were X-rayed and had blood samples taken in the department. Now, patients are quickly assessed and sent straight away to the CCU. If there is an unavoidable delay in the department it is recommended that thrombolysis should begin in the A & E Department. There was unacceptable delay before treatment even for patients admitted directly from a G.P. to the CCU. Some of the delay was the time required to prepare the infusion, and on some occasions a doctor was not immediately available to assess the patient. Since the study, our aim is to administer thrombolytic drugs within 30min of admission in appropriate cases, but achievement of this has yet to be evaluated. Senior CCU nurses can usefully ensure that all staff, including the A & E staff, are aware of the necessity for early treatment to ensure the full value of thrombolysis in reducing mortality.
THE NURSING ROLE IN THE CARE OF PATIENTS HAVING THROMBOLYSIS Streptokinase
is the
most
commonly
used
thrombolytic agent at present. It promotes thrombolysis by a complex series of events leading to dissolution of the thrombus in the occluded coronary artery and is usually added to an infusion of 50-100mls of saline given over 1 h. Aspirin is usually given immediately on admission, as it has additive benefit with streptokinase mainly in preventing re-occlusion resulting in re-infarction (ISIS 2, 1988). Nurses can play a large part in the identification of potential patients for thrombolytic therapy and need to understand fully the indications, implications, and contraindications of the treatment. The nursing role consists of explaining the treatments to the patient and family, and observing the patient closely for any adverse effects of the treatment. These include the risk of bleeding, allergic reaction and the risks of possible adverse effects due to reperfusion of the myocardium. Minor bleeding is most frequent at puncture sites, and invasive procedures should be avoided as far as possible after thrombolysis. The most feared complication is cerebral haemorrhage this can occur in 0.5% - 1% of patients treated (ISIS 2, 1988). The problem of allergy and anaphylaxis is a minor one but nevertheless can occur. The problem of hypotension is perhaps more common following streptokinase. If hypotension is marked or persistent, or allergic reaction occurs, the infusion should be discontinued and Actilyse (RTPA) considered, which is a non-allergenic thrombolytic agent which tends not to effect the blood pressure. The nursing role is not only close observation of the patient for adverse effects. Nurses are in a prime position to assess whether the treatment is working. Signs of reperfusion include reduction in S-T elevation on the electrocardiogram (ECG), development of reperfusion arrhythmias, relief of chest pain. It is useful to take a 12 lead ECG a few hours after completion of the
INTENSIVEANDCRITICALCARENURSING
infusion. If S-T elevation is still present, this is a sign that reperfusion has not salvaged all viable (injured) myocardium and an infusion of nitrates may be considered for its vasodilator effects. Further information on the effects of not only nitrates, but of captopril and magnesium on infarct size and mortality will be available when the results of the next ongoing ISIS trial (ISIS 4) are published. Reperfusion arrhythmias are the best known reperfusion complication but are usually only minor, for example transient bradycardia or idioventricular rhythm. Ventricular fibrillation may be provoked but overall incidence is reduced rather than increased (Chamberlain, 1989). Reperfusion arrhythmias should be noted and documented, and such observations passed on to the medical staff. Relief of chest pain in relation to thrombolysis is more difficult to assess, as the patient in pain has usually been given an analgesic on admission to hospital. Chest pain only partially relieved by opiates may be fully relieved by thrombolysis.
SUBSEQUENT NURSING CARE Many of the patients have an uncomplicated course without any significant arrhythmias or disturbance of cardiac function. At the other end of the scale there will be patients with severe disturbances of cardiac rhythm and/or heart failure. Close observation of heart rate and rhythm, blood pressure, urine output, to identify any early signs of heart failure should be a priority with all patients. Early detection and treatment may prevent deterioration in an patient’s clinical status. Invasive procedures such as temporary pacing, insertion of central lines or pulmonary artery catheters are needed in a fair proportion of patients. Electrical cardioversion is necessary for patients with sustained tachyarrhythmias who are haemodynamically unstable, and for patients who have not responded to drug therapy. A large part of nurses’ time should be spent talking and listening to patients and their fami-
87
lies and attempting to allay fears. Various kinds of psychological and environmental stress can increase the risk of cardiac arrhythmias, particularly when there is myocardial ischaemia. CCU nurses are the people most in contact with the patients and are an important part of the environment - the most important part some patients have said (Burke, 198 1). Perhaps one of the CCU nurses’ most important functions is communication, which can help give patients the confidence, peace of mind and the knowledge needed to take an active part in their recovery (Ashworth, 1985). There are various reasons why nurse-patient communication may be inadequate in coronary care. These include the short duration of patients’ stay on the unit, the severity of their condition and, often, the nurses’ pre-occupation with handling technical rather than personal requirements. It is important for the communication to be clear, using language familiar to the patient (at whatever level), and avoiding the use of jargon. Simple explanations need reiterating, since verbal information on medical matters is seldom retained for long (Thompson, 1989). Primary nursing is practised in the CCU at Scarborough District General and involves a one-to-one relationship with each patient and family. Verbal and written information is given to patients in the CCU and continued throughout each patient’s stay in hospital. A CCU primary nurse is responsible for coordinating this information throughout each patient’s stay in hospital; follow-up visits are made to the patient on the medical wards to continue counselling and education. Studies have revealed that patients only retain a small amount of the verbal information given to them, particularly when this information is given early in the post-infarction phase, so they need information to be repeated and enlarged upon during convalescence (Burke, 1981). A study in 1985 investigating communication between patients, relatives and nurses in a CCU revealed that only 50% of patients and 37% of relatives were happy with the level of communication of information about heart attacks. Many of these expressing dissatisfaction qualified their
88
INTENSIVE
AND CRITICAL
CARE NURSING
comments by saying they were ‘sure they would have been told, if they asked. It is clear from these results that at least for a proportion of the population it is not reasonable for staff to assume . . . ‘they will ask if they want to know’ (Farrel et al, 1985). In an attempt to improve patients’/relatives’ knowledge and lessen anxiety in a busy CCU we decided to provide written information about the care given in conjuction with a totally patientorientated care plan. This care plan/information reinforces verbal information given to patients and relatives and is kept at the bedside so that
patients and their families can refer to it. But who benefits most from reading care plans, the patients or the nurses? It is our philosophy that each patient is a partner in care, and that the nurse writes a care planfor thepatient, updating it as necessary. Important nursing information is repeated on an evaluation form which contains a list of nursing problems, kept in a separate file not at the bedside. Ths enables the patient to become the owner of his care plan throughout his hospital stay. A standardised ‘care plan’ is used with individual problems written on it as required (Fig. 2).
Fig. 2 Scarborough Health Authority Nursing Records Nursing Care Plan and Information Sheet for: Consultant: Registrar/Senior House Officer: House Officer:
Coronary Care Nurse: Coronary Care Sister: Cardiac Rehabilitation Sister: (i)
Date
Problem or potential problem A) Chest pain due to a possible heart attack.
Nurse signature
Action Please inform the nursing staff of any chest pain or discomfort however slight. It is important that the staff are aware of the type, site duration of the pain to differentiate ‘heart pain’ from pain due to other causes. Pain relief is available as needed. The diagnosis of a heart attack is made essentiallv in 3 steos:1. The patient’s symptoms. 2. The electrocardiographs or heart tracings. These are taken every day for 3 days. 3. Results of blood tests - ‘cardiac enzymes’. Cardiac enzymes are released from the heart muscle into the blood stream, a high level may indicate a heart attack has occurred. These blood tests are also taken every day for 3 days. Because of the need to complete these tests, your diagnosis may be unclear until 2 or 3 days have passed but, in many cases, it is possible for the doctor to make the diagnosis earlier. (ii)
INTENSIVE
Problem or potential problem
Date
. has been given via a drip in your arm (this is a thrombolytic drug).
AND CKI1‘ICAL
CAKE NURSING
Nurse signature
Action A heart attack is caused by the sudden formation of a clot inside a coronary artery (blood vessel). The artery is nearly always narrowed and already partially roughened by cholesterol deposits. In a heart attack, part of this abnormal lining can break off or crack leaving a raw surface. Blood clot can then form on this raw surface, causing a sudden complete blockage of that artery. Thrombolytic drugs dissolve the blood clot and so re-open the artery and restore the blood supply to the area of heart supplied by that artery. This minimises the amount of damage to the heart. (iii)
Problem or potential problem
Date
B) Possibility of a change in heart rate or rhythm, blood pressure or temperature following a heart attack.
Nurse signature
Action You will be attached to a cardiac monitor for a few days to enable the nursing staff to observe for any changes which may require treatment. The reading on the bedside monitor is transmitted to a larger central monitor at the nurses’ station to enable the nurses to observe your heart rate and rhythm when not at the bedside. The ‘monitor alarms’ will be explained to you. Don’t worry about the monitor. Most people don’t need treatment for changes in heart rhythms. If you do, any problems are usually easily treatable. Your blood pressure and temperature will be checked at frequent intervals. A slight rise in temperature is normal after a heart attack. Changes in blood pressure readings can occur, particularly if you have been given any drugs for the heart. (iv)
Problem or potential oroblem
Date
Nurse signature
C) Possibility of fluid accumulation in the lungs and/or other parts of the body following a heart attack. Dehydration is also a possibility if you have been vomiting or sweating excessively.
The nursing staff will record the amounts of fluid you drink and the amounts of urine you pass, to monitor this for a few days.
D) ‘Venflon’ cannula sited in an arm vein.
This is a route for any drugs which may need to be given into a vein. It avoids the need for injections. If the site becomes sore or inflamed please inform the nurses. After 3 or 4 days it will be taken out. W
LCN.
S
89
90
Date
lNTENSIVEANDCRITICALCARE NURSING Problem or potential problem
Nurse signature
Action
E) Possibility of constipation.
Lack of muscular movement whilst on bedrest, change in diet and side effects of some medications you may have been given, all predispose to constipation. It is normal not to have your bowels open for 3 days or longer in these circumstances. To prevent this from becoming a problem, a mild laxative will be given the day after admission or sooner if you require it. It is important to take the laxative as ‘straining’ to open your bowels can cause an excessive strain on the heart.
F) Possibility of pressure areas developing (i.e. reddened sore areas on buttocks, heels, elbows) due to bed rest.
Change your position in bed at frequent intervals, if you need help the nursing staff will assist.
G) Possibility of venous thrombosis (blood clot formation in a vein) as a result of reduced circulation due to bed rest.
Deep breathing and leg exercises will be advised by the physiotherapist and nursing staff (see separate sheet).
(vi)
Date
Problem or potential problem HI You may feel anxious due to a strange environment, equipment and uncertainty about your diagnosis.
Nurse signature
Action All equipment and tests will be explained to you and your family. Information regarding your diagnosis will be given to you by both medical and nursing staff. We are here to answer any questions you or your family may have, so please ask. (vii)
Problem or potential problem Possible need for a change in life-style
Nurse signature
Action Your risk of having a further heart attack will be assessed by looking at the factors which cause heart attacks. A tendency to coronary heart disease can be inherited, something which you cannot do anything about, but most other major causes of heart attacks are preventable, e.g. -
Smoking - 20 cigarettes a day doubles your risk of a heart attack. High blood pressure-this can also be inherited. Diet - high cholesterol (animal fats) Overweight.
Complete protection against having another heart attack cannot be guaranteed but the risk can be reduced by following advice on modifying your lifestyle. Risk factors
........
Recommendad
action..
(viii)
................
INTENSIVE
Date
AND CRITICAL
CARE NURSING
Nurse signature
Problem or potential problem
Action
J) Getting back to normal. Information and advice.
Gradually you will be able to return to your previous level of mobility. At first you will need to stay in bed although you will be able to sit in a chair for short periods. In approximately 2 or 3 days you will be transferred on to a general medical ward and you will be able to begin walking about-see separate sheet. The ward environment is quite different from the Coronary Care Unit. You will not require the same level of observation or attention from the nursing staff. Think of moving on to the ward as a step forward and a step nearer to going home. The usual time for discharge home is 7-10 days after admission. Most people return to work after 2-3 months. Relevant advice and leaflets will be given to you and your family, including information about ‘The Cardiac Rehabilitation Programme’ at Scarborough Hospital. If tests show you have not had a heart attack, you may be able to begin mobilizing sooner and be discharged home earlier. Relevant information and advice will be given to you. (ix)
General information Viiiting
Your family and close friends may visit at any time for short periods, except between 1 .OO- 2.30pm (rest period).
Boredom
Television, radio cassette, magazines and a few books are available - please ask. Newspapers are available on a daily basis.
Meal Times
Breakfast Lunch Tea/Supper
Nursing staff
One nurse will be allocated to be responsible for your care during your stay in the Unit. When this nurse is off duty, other coronary care nurses will care for you. If you have any questions, comments or complaints, please feel free to ask your nurse or the coronary care Sister.
8.00-8.30am 12.30-l.OOpm 6.00-6.30pm
You will be seen on a daily basis by a senior doctor and by the Consultant in charge of your treatment periodically during your stay in hospital. fx)
91
92
INTENSIVEANDCRITICALCARENURSINC
The care plan was devised in consultation with of the patients and staff. An evaluation effectiveness of the written information contained within it has taken place. A questionnaire was completed by 30 patients (see Fig. 3) of whom 100% were in favour of receiving written information about their care plan in the CCU. They indicated that they felt less anxious about their stay in the unit because of it. All the patients who completed the questionnaire wanted the care plan at the bedside for relatives and close friends to read, and thought it made them also less anxious about the care in the unit. The care plan is usually given to patients the day after admission or when they are well enough to read it, and is discussed with the primary nurse before it is left at the bedside.
Please tick appropriate
box.
1) Do you think it is helpful to have written information about your care in the Coronary Care Unit, or would you prefer just a verbal explanation? Verbal only 0 Verbal and written 0 2) Would you prefer not to have been given any of this information, either verbally or written, during your stay in the Coronary Care Unit? Would prefer not to be given the information Would prefer the information 0 3) Do You feel that having information you in this way has made you:
0
presented to
a) Less anxious about your care in CCU 0 b) More anxious about vour care in CCU 0 ci It has not affected yobr anxiety levels in either way Cl 4 Do you think the care plan/information sheet should be left at the bedside for your relatives or close friends to read?
Additional written information is given in the form of booklets relevant to the patient’s condition, with advice on medication and the cardiac rehabilitation programme, and videos are shown. Both structured and informal discussion with the patient and his family about the information documented in the care plan has proved an excellent means of communication and facilitates education of patients, junior staff and learners. Directing the written information to patients e.g. asking the patient to inform the nursing staff of any chest pain or discomfort however slight, and backing this up with the reasons why, reinforces the patients’ understanding of their condition, and creates an informal relaxed atmosphere where both patients and relatives feel free to ask questions and discuss problems at any time. Fortunately there is a cardiac rehabilitation sister based in CCU who takes referrals from primary nurses. When time, staffing and circumstances permit, the primary nurses are able to visit their patients at home with the rehabilitation nurse. We feel not only able to care for our patients’ physical needs, but that psychological care and rehabilitation is a top priority. In a busy unit with a large throughput of patients our philosophy of care and method of primary nursing ensures that very few patients ‘slip through the net’ and the majority receive support and advice from a coronary care nurse from hospital admission to discharge, and in the subsequent weeks at home.
Acknowledgements
Did they read it? If so did it make them: a) Less anxious about your care in CCU 0 b) More anxious about your care in CCU 0 c) Did not affect their anxiety levels either way 0 ANY FURTHER COMMENTS:
Fig. 3 Patient evaluation of the care plan/information sheet used in coronary care
I would like to thank Clare Garlick, Jeffrey Caunt for their encouragement this article.
Sue Malton and in the writing of
References Ahdellah F 1972 The nursing role in the Coronary Care System - In: Meltzer L E, Dunning A J Textbook of Coronary Care. Charles Press, Maryland pp 35-51 Ashworth P M 1985 Don’t forget to talk to them. Nursing Mirror 160 (18): 51-52
Ih'TENSIVEAND<:RITI~:AL(:ARENURSIN(; 93 Burke L E 198 I Learning and retention in the acute care setting - Critical Care Quarterly 4 (4): 67-73 Caunt J E 1987 The three minute mile. Senior Nurse 6 (5): 14-16 Chamberlain D A 1989 Thrombolysis in the treatment of acute myocardial infarction. Care of the Criticially III 5 (5): 180-181 Collaborative Croup 1988 ISIS 2 trial (Second International Study of Infarct Survival) Randomized trial of intravenous streptokinase, oral aspirin, both or neither amongst 17 187 cases of suspected myocardial infarction. Lancet 2: 349-60 Department of Health and Social Security (DHSS) Circular (1989) the extending role of the clinical nurse; legal implications and-training requirements. PUCMO (89) 7. PUCNO (89) IO Farrel J, Booth’ E,’ Hayburn T 1$85 Telling it straight. Nursing Mirror 160 (la): 51-52 GISSI trial 1986 Effectiveness of intravenous thrombolytic in acute myocardial infarction. Lancet 1 397-402 Glazier et al 1986 American Journal of Cardiology 586 (58): 667-672
Jowett N, Thompson D 1989 Introduction to coronary care. In: Comprehensive Coronary Care - Scutari Press, Harrow: p. 11 Joy M 1989 General management of the coronary patient - Care of the critically ill. 5 (5): 182-184 Kukin M et al 1990 Acute myocardial infarction, special care units, analgesia and complications. Current Opinion in Cardiology 5: 42 l-426 Meltzer L E, Pinneo R et al 1989 System of intensive coronary care - a manual for nurses. Charles Press, Maryland, pp 25-29 Reynell P C 1983 Self admission for myocardial infarction. British Heart Journal 49: 364-367 Thompson D 1987 Management of the patient with acute myocardial infarction. Nursing Standard 9 (4): 34-38 Townsend A 1988 Management of pain in patients with yi;crdial infarction. Intensive Care Nursing 4 (1): Willetts K 1989 Assessing 85 (4): 52-54
cardiac
pain.
Nursing
Times
GroupUK
Ltd 1992
The changing role of coronary care nurses Jane E. Caunt
The purpose in this article is to give an overview of the role of a coronary care nurse. No attempt is made to give a detailed account of any particular aspect of care but rather to inspire coronary care nurses to think about their practice and what can be achieved. In the 1960s Coronary Care Units (CCUs) were shown to reduce mortality from fatal arrhythmias and nursing care was based around observation and emergency treatment. The focus of coronary care is now moving towards infarct size reduction and the prevention of infarction in patients with unstable angina. Nurses are adapting their role accordingly - the skill, knowledge and judgement required to recognise reversible ischaemic episodes in the early pre- or post-infarctional period is paramount. It is equally and vitally important that nurses are able to recognise and assess the psychological and rehabilitation needs of patients. These aspects of care can be met ideally by using a system based on primary nursing and focusing on the patients’ individual needs. Nursing practice should be research-based, and under constant review with positive change encouraged.
INTRODUCTION Almost 30 years have elapsed since the advent of the first CCUs in the early 1960s. Before the introduction of intensive coronary care at least 30% of all patients admitted to hospital with acute myocardial infarction died during the period of hospitalisation. But with the introduction of a Coronary Care Unit, the mortality rate fell to around 15%, mainly due to the early detection and immediate treatment of life-
Jane E. Caunt RGN, ENB 124,112 Moor Lane, Newby, Scarborough,
North Yorkshire, Y012 5SP
(Requests for offprints to JCI Manuscript
82
accepted 75 February 7992
threatening arrythmias, which accounted for 47% of deaths (Meltzer, 1961). Most of the success of the system was attributed to the skillsof specially trained nurses who were able to interpret the electrocardiographic findings displayed on the cardiac monitors and recognise the significance of changes in cardiac rate and rhythm. They were able to assess the clinical condition of patients repeatedly by planned, careful observation in order to detect signs of the complications of myocardial infarction. Most importantly the reduction in mortality was due to nurses being able to assume a decision-making role in emergency situations and defibrillate patients immediately instead of awaiting the arrival of the medical team (Meltzer, 1962).
INTENSIVE
Even so, particularly in Britain, it took a long time for hospitals to recognise that their newly developed CCUs needed not only expensive monitoring and resuscitation equipment but the specially trained and highly skilled nurses to go with it; nurses with delegated authority to make and carry out therapeutic decisions based on their own observations and judgement. In practice this entails interpretation of arryhthmias, emergency defibrillation, administration of emergency intravenous drug therapy (Meltzer, 1962). More recent findings again support their view that to avoid delays in vital treatment all nurses, particularly those working in coronary care areas, should be trained to defibrillate and given the authority to do so. One study of local policies and procedures highlights the delays which can occur from onset of ventricular fibrillation to defibrillation whilst awaiting the arrival of a doctor. In this particular study in one hospital the mean time from a cardiac arrest to arrival of a doctor was 2 min and 23s. In this hospital the coronary care nurses were not given the authority to defibrillate. In contrast, in a hospital where coronary care nurses weregiven this authority, the average time from onset of an immediately life-threatening arrhythmia to treatment with the defibrillator was 26s, the shortest time being 12s and the longest 35s (Caunt, 1987). Even now, there are CCIJs in the United Kingdom where these basic components of coronary care nursing are not practised. Most practising coronary care nurses find such a situation inexcusable and feel that it is gross negligence of some nurse managers who appear to discourage such practice, and in some cases oppose it. Nowadays there are newer drugs to suppress arrhythmias, vasodilators, beta-blockers and angiotensin converting enzyme (ACE) inhibitors and, in the last few years, the use of thrombolytics and aspirin therapy has become routine in coronary care units and has reduced mortality rate by a further 25% (ISIS 2, 1988). Cardioversion and resuscitation techniques have improved. Temporary and permanent pacemaker support, angiography, angioscopy,
AND CRITICAL
CARE NURSING
83
angioplasty and surgical techniques are available. The greatest benefit in terms of mortality may eventually come from primary prevention, but information on secondary prevention with improved drug therapies, surgical techniques, angioplasty and cardiac rehabilitation also shows a reduction in both mortality and morbidity (Joy, 1989). Despite these improved figures, the need for acute coronary care will remain and there is presently a trend towards an increase in the number of admissions to CCUs due to:
1) an increased referral rate from general practitioners (GPs) of patients to receive urgent thrombolysis, who might otherwise have been left at home 2) an increasing number of elderly people who are living longer as a direct result of thrombolysis 3) extended life-saving skills of paramedic/ ambulance personnel resulting in more patients being delivered to hospital alive 4) an increased public awareness of the symp toms of a heart attack.
CORONARY CARE NURSING TODAY Good coronary care nursing is based upon general nursing principles, to help the patient maintain and regain as near normal a lifestyle as possible and perform daily activities. These nurses need to be competent in assessing the various needs of patients and their families to ensure the provision of physical safety comfort, and emotional support. Emotional support is vital to help each patient to overcome not only the illness itself but hospitalisation and therapy in an alien and technical environment which can be an anxiety-provoking, stressful experience (Jowett & Thompson, 1989). Each nurse must be able to assess and interpret the patients’ needs, set priorities, make judgements and take the necessary actions. It is only in addition to this that she/he needs to be skilled in technological advances. Most patients are totally
84
lNTENSlVEANDCRlTlCALCARENURSlNG
reliant on nursing support, whether being revived following cardiac arrest or in need of emotional support for themselves or their families. It is distressing to realise that without adequate training, experience and understandcare nurses can ing of their role, coronary become more skilled at technical and invasive manoeuvres than in recognising the need for them (Jowett & Thompson, 1989). With the advent of the English National Board 124 Coronary Care course and comprehensive teaching programmes within individual units, many nurses are highly skilled and committed to their work. Defibrillation, emergency intravenous drug therapy, recording and interpretation of electrocardiography have become normal practice in many coronary care units. Experienced coronary care nurses are probably more skilled and knowledgeable about these than many doctors, and yet these duties are still deemed part of an extended role and have to be officially delegated by doctors. If these skills are an accepted part of the CCU nurse’s role, should they be delegated by members of another profession? Or should nurses be talking about the need to expand the role of nurses officially and continue to provide suitable training within the Coronary Care Unit teaching programmes and ENB courses? This is not to say that doctors should not be involved in the teaching of nurses - this should be wholly welcomed - but should it be a requirement for certificates of competence to be signed by a doctor? (DHSS, 1989)
NURSE-DOCTOR RELATIONSHIP Both nursing and medical staff need to demonstrate interpersonal confidence and trust, with good communication and mutual support. The concept of coronary care nursing is based upon a team approach with the nurse and attending physician sharing the responsibility for patient care (Abdellah, 1972). Frequently their work overlaps, particularly in technical areas, but nurses must not lose sight of their role and become too opinionated where medical treatment is concerned. otherwise thev mav give the
impression of being anti-doctor, which is counter-productive and can cause a fractious working atmosphere (Jowett & Thompson, 1989).
PRIORITIES ON ADMISSION Admitting a patient to CCU involves a sequence of priorities, the final order of which is determined by the nurse. The critical factor in establishing priorities is the patient’s clinical condition and needs at the time of admission. Pain, fear and apprehension are almost invariably present in patients suffering evolving myocardial infarction. The pain of acute myocardial infarction is principally due to on-going ischaemia of viable but threatened myocardial tissue rather than necrosis. Conversely patients with the electrocardiographic signs of silent ischaemia or infarction may have impaired central responses to painful stimuli, therefore do not ‘feel’ the pain (Glazier et al, 1986). Proper evaluation and management of chest pain or its equivalent in patients with silent ischaemia/ infarction requires speed, skill and compassion. Oxygen and nitrates reduce the ischaemia (Kukin et al, 1990) but most patients require at least 5 mg of diamorphine intravenously together with an anti-emetic. This relieves the pain and anxiety and can reduce the risk of arrhythmias. Doses of less than 5 mg diamorphine are rarely effective in definitive myocardial infarction except in very frail small-framed individuals (Townsend, 1988). Large-framed patients may need larger initial doses, e.g. 1Omg. Marked respiratory depression following administration of opiates can occur in individuals unusually sensitive to their effects, or those with chronic airways disease, which highlights the need for patient’s assessment of each careful requirements. All coronary care nurses who administer diamorphine should be fully conversant with the indications, contraindications and side-effects of this drug (as with any other drug administered). The knowledge levels of some coronary care nurses about diamorphine and its effects are
INTENSIVE
clearly inadequate, as demonstrated by Willets’ study in 1989. She handed out 40 questionnaires to nurses working in the CCUs of two district hospitals. Although the nurses in the survey were well aware that effective pain control plays an important part in limiting infarction size, their actual knowledge of the effects of diamorphine was relatively very poor. For example only 4 1% knew that maximal respiratory depression is reached within 5 to 10min of intravenous injection and only 25% knew that diamorphine’s peak analgesic effect is reached within 20 min of intravenous administrations. The same study also highlights the fact that, in general, pain relief in CCUs is inadequate. 80% of patients in her survey said that their pain never really disappeared throughout their stay in the CCU, and 40% of these said that their anxiety about their condition was increased during this time. The traditional treatment of pain with nitrates and diamorphine given ‘when necessary’ (p.r.n.) needs to be reconsidered (Willetts, 1989). During recent years continuous infusions of nitrates have become fairly standard practice for some patients nursed in CCUs, as a treatment for ischaemic cardiac pain, silent ischaemia and control of left ventricular failure. It is vital that nurses know how to assess cardiac pain properly in order to differentiate it from the many other causes of chest pain and thereby administer appropriate analgesia. It is not uncommon for a patient with ‘unresolved chest pain’ 24 h or so after admission to be given an assortment of remedies, e.g., nitrates, paracetamol, gaviscon, as no-one is quite sure whether the pain is cardiac or not. Assessment is often hindered by the apparent inability of the patient to express the exact location and character of the pain. The continuation or recurrence of the pain in the hours or days after treatment has begun does not invariably mean clinical deterioration or extension of infarction. Often the pain is due to inflammatory processes manifesting as the clinical myopericarditis syndromes, and selection of optimum analgesic medication should move from potent narcotics given intravenously to orally-administered non-steroidal anti-
AND CRITICAL
CARE NURSING
85
inflammatory preparations, e.g. indomethacin (Kukin et al, 1990). In a CCU it is nurses who assess the effectiveness of analgesia and as patients’ advocates they should encourage doctors to prescribe adequate and appropriate analgesia. It is the nurses’ responsibility to get treatment reviewed if it is ineffective (Willetts, 1989). However it should be remembered that there are many variables which may influence the management of pain. These include the promotion of a calm, restful environment, the teaching of relaxation, the patients’ ability to carry this out and the ability of each patient to understand the reasons for his/her pain, and the importance of reporting it as it arises. Patients should be admitted rapidly as time is crucial. Up to 50% of patients who die within the first 28 days following a myocardial infarction do so within the first hour, commonly from arrhythmias which should be preventable with adequate monitoring. Thrombolytic drugs should be administered urgently to appropriate patients, as they are most effective when given as soon as possible after the onset of symptoms (ISIS 2, 1988). These drugs dissolve thrombus, namely the clot in the coronary artery which is causing the infarction, thereby restoring the blood supply to that area of myocardium. This minimises the damage and in some cases, if given early enough, reverses the process of the heart attack. The ISIS 2 (1988) study investigating the effectiveness of thrombolysis showed that in a number of nations including the UK only 24% of patients were admitted within 3 h of onset of symptoms. A similar Italian study (GISSI, 1986) showed that 52% of patients were admitted within 3 h of symptoms first occurring. Coronary care nurses can play a major role in educating patients regarding when to call an ambulance or contact a GP, should chest pain recur at home following hospital discharge. Records can be kept within CCUs of the time interval between ‘onset of acute symptoms’ and admission to CCU and possible sources of delay identified. Direct admission to CCU of patients referred by a GP, by-passing the Accident and Emergency
86
INTENSIVEANDCRITICALCARENURSING
Fii. 1 Reasons for delay Name 1. 2. 3. 4. 5.
Diagnosis
Time onset of symptoms Call to GP/Ambulance Arrival at A & E Arrival at CCU Time of thrombolytic -
Department, (A & E) has been shown to reduce delay. Also success in reducing delay has been possible where high risk patients with known coronary artery diseases have been advised to refer themselves to hospitals when necessary, without any increase in inappropriate referrals (Reynell, 1983). Despite the importance of early thrombolysis, unacceptable delays in initiating it still occur in hospital. In order to put this delay in perspective we undertook a small study of 49 patients in Scarborough District General Hospital to monitor the time lapse (Fig. 1). Until a decision was taken to try and reduce the time lapse from patients’ arrival at the hospital to initiation of thrombolysis the median time was 1 h 7 min shortest time was about 28 min. As a lot of the delays occurred with patients admitted via the A & E Department, we have since shown a need to alter the admission procedure there. Before the study patients were X-rayed and had blood samples taken in the department. Now, patients are quickly assessed and sent straight away to the CCU. If there is an unavoidable delay in the department it is recommended that thrombolysis should begin in the A & E Department. There was unacceptable delay before treatment even for patients admitted directly from a G.P. to the CCU. Some of the delay was the time required to prepare the infusion, and on some occasions a doctor was not immediately available to assess the patient. Since the study, our aim is to administer thrombolytic drugs within 30min of admission in appropriate cases, but achievement of this has yet to be evaluated. Senior CCU nurses can usefully ensure that all staff, including the A & E staff, are aware of the necessity for early treatment to ensure the full value of thrombolysis in reducing mortality.
THE NURSING ROLE IN THE CARE OF PATIENTS HAVING THROMBOLYSIS Streptokinase
is the
most
commonly
used
thrombolytic agent at present. It promotes thrombolysis by a complex series of events leading to dissolution of the thrombus in the occluded coronary artery and is usually added to an infusion of 50-100mls of saline given over 1 h. Aspirin is usually given immediately on admission, as it has additive benefit with streptokinase mainly in preventing re-occlusion resulting in re-infarction (ISIS 2, 1988). Nurses can play a large part in the identification of potential patients for thrombolytic therapy and need to understand fully the indications, implications, and contraindications of the treatment. The nursing role consists of explaining the treatments to the patient and family, and observing the patient closely for any adverse effects of the treatment. These include the risk of bleeding, allergic reaction and the risks of possible adverse effects due to reperfusion of the myocardium. Minor bleeding is most frequent at puncture sites, and invasive procedures should be avoided as far as possible after thrombolysis. The most feared complication is cerebral haemorrhage this can occur in 0.5% - 1% of patients treated (ISIS 2, 1988). The problem of allergy and anaphylaxis is a minor one but nevertheless can occur. The problem of hypotension is perhaps more common following streptokinase. If hypotension is marked or persistent, or allergic reaction occurs, the infusion should be discontinued and Actilyse (RTPA) considered, which is a non-allergenic thrombolytic agent which tends not to effect the blood pressure. The nursing role is not only close observation of the patient for adverse effects. Nurses are in a prime position to assess whether the treatment is working. Signs of reperfusion include reduction in S-T elevation on the electrocardiogram (ECG), development of reperfusion arrhythmias, relief of chest pain. It is useful to take a 12 lead ECG a few hours after completion of the
INTENSIVEANDCRITICALCARENURSING
infusion. If S-T elevation is still present, this is a sign that reperfusion has not salvaged all viable (injured) myocardium and an infusion of nitrates may be considered for its vasodilator effects. Further information on the effects of not only nitrates, but of captopril and magnesium on infarct size and mortality will be available when the results of the next ongoing ISIS trial (ISIS 4) are published. Reperfusion arrhythmias are the best known reperfusion complication but are usually only minor, for example transient bradycardia or idioventricular rhythm. Ventricular fibrillation may be provoked but overall incidence is reduced rather than increased (Chamberlain, 1989). Reperfusion arrhythmias should be noted and documented, and such observations passed on to the medical staff. Relief of chest pain in relation to thrombolysis is more difficult to assess, as the patient in pain has usually been given an analgesic on admission to hospital. Chest pain only partially relieved by opiates may be fully relieved by thrombolysis.
SUBSEQUENT NURSING CARE Many of the patients have an uncomplicated course without any significant arrhythmias or disturbance of cardiac function. At the other end of the scale there will be patients with severe disturbances of cardiac rhythm and/or heart failure. Close observation of heart rate and rhythm, blood pressure, urine output, to identify any early signs of heart failure should be a priority with all patients. Early detection and treatment may prevent deterioration in an patient’s clinical status. Invasive procedures such as temporary pacing, insertion of central lines or pulmonary artery catheters are needed in a fair proportion of patients. Electrical cardioversion is necessary for patients with sustained tachyarrhythmias who are haemodynamically unstable, and for patients who have not responded to drug therapy. A large part of nurses’ time should be spent talking and listening to patients and their fami-
87
lies and attempting to allay fears. Various kinds of psychological and environmental stress can increase the risk of cardiac arrhythmias, particularly when there is myocardial ischaemia. CCU nurses are the people most in contact with the patients and are an important part of the environment - the most important part some patients have said (Burke, 198 1). Perhaps one of the CCU nurses’ most important functions is communication, which can help give patients the confidence, peace of mind and the knowledge needed to take an active part in their recovery (Ashworth, 1985). There are various reasons why nurse-patient communication may be inadequate in coronary care. These include the short duration of patients’ stay on the unit, the severity of their condition and, often, the nurses’ pre-occupation with handling technical rather than personal requirements. It is important for the communication to be clear, using language familiar to the patient (at whatever level), and avoiding the use of jargon. Simple explanations need reiterating, since verbal information on medical matters is seldom retained for long (Thompson, 1989). Primary nursing is practised in the CCU at Scarborough District General and involves a one-to-one relationship with each patient and family. Verbal and written information is given to patients in the CCU and continued throughout each patient’s stay in hospital. A CCU primary nurse is responsible for coordinating this information throughout each patient’s stay in hospital; follow-up visits are made to the patient on the medical wards to continue counselling and education. Studies have revealed that patients only retain a small amount of the verbal information given to them, particularly when this information is given early in the post-infarction phase, so they need information to be repeated and enlarged upon during convalescence (Burke, 1981). A study in 1985 investigating communication between patients, relatives and nurses in a CCU revealed that only 50% of patients and 37% of relatives were happy with the level of communication of information about heart attacks. Many of these expressing dissatisfaction qualified their
88
INTENSIVE
AND CRITICAL
CARE NURSING
comments by saying they were ‘sure they would have been told, if they asked. It is clear from these results that at least for a proportion of the population it is not reasonable for staff to assume . . . ‘they will ask if they want to know’ (Farrel et al, 1985). In an attempt to improve patients’/relatives’ knowledge and lessen anxiety in a busy CCU we decided to provide written information about the care given in conjuction with a totally patientorientated care plan. This care plan/information reinforces verbal information given to patients and relatives and is kept at the bedside so that
patients and their families can refer to it. But who benefits most from reading care plans, the patients or the nurses? It is our philosophy that each patient is a partner in care, and that the nurse writes a care planfor thepatient, updating it as necessary. Important nursing information is repeated on an evaluation form which contains a list of nursing problems, kept in a separate file not at the bedside. Ths enables the patient to become the owner of his care plan throughout his hospital stay. A standardised ‘care plan’ is used with individual problems written on it as required (Fig. 2).
Fig. 2 Scarborough Health Authority Nursing Records Nursing Care Plan and Information Sheet for: Consultant: Registrar/Senior House Officer: House Officer:
Coronary Care Nurse: Coronary Care Sister: Cardiac Rehabilitation Sister: (i)
Date
Problem or potential problem A) Chest pain due to a possible heart attack.
Nurse signature
Action Please inform the nursing staff of any chest pain or discomfort however slight. It is important that the staff are aware of the type, site duration of the pain to differentiate ‘heart pain’ from pain due to other causes. Pain relief is available as needed. The diagnosis of a heart attack is made essentiallv in 3 steos:1. The patient’s symptoms. 2. The electrocardiographs or heart tracings. These are taken every day for 3 days. 3. Results of blood tests - ‘cardiac enzymes’. Cardiac enzymes are released from the heart muscle into the blood stream, a high level may indicate a heart attack has occurred. These blood tests are also taken every day for 3 days. Because of the need to complete these tests, your diagnosis may be unclear until 2 or 3 days have passed but, in many cases, it is possible for the doctor to make the diagnosis earlier. (ii)
INTENSIVE
Problem or potential problem
Date
. has been given via a drip in your arm (this is a thrombolytic drug).
AND CKI1‘ICAL
CAKE NURSING
Nurse signature
Action A heart attack is caused by the sudden formation of a clot inside a coronary artery (blood vessel). The artery is nearly always narrowed and already partially roughened by cholesterol deposits. In a heart attack, part of this abnormal lining can break off or crack leaving a raw surface. Blood clot can then form on this raw surface, causing a sudden complete blockage of that artery. Thrombolytic drugs dissolve the blood clot and so re-open the artery and restore the blood supply to the area of heart supplied by that artery. This minimises the amount of damage to the heart. (iii)
Problem or potential problem
Date
B) Possibility of a change in heart rate or rhythm, blood pressure or temperature following a heart attack.
Nurse signature
Action You will be attached to a cardiac monitor for a few days to enable the nursing staff to observe for any changes which may require treatment. The reading on the bedside monitor is transmitted to a larger central monitor at the nurses’ station to enable the nurses to observe your heart rate and rhythm when not at the bedside. The ‘monitor alarms’ will be explained to you. Don’t worry about the monitor. Most people don’t need treatment for changes in heart rhythms. If you do, any problems are usually easily treatable. Your blood pressure and temperature will be checked at frequent intervals. A slight rise in temperature is normal after a heart attack. Changes in blood pressure readings can occur, particularly if you have been given any drugs for the heart. (iv)
Problem or potential oroblem
Date
Nurse signature
C) Possibility of fluid accumulation in the lungs and/or other parts of the body following a heart attack. Dehydration is also a possibility if you have been vomiting or sweating excessively.
The nursing staff will record the amounts of fluid you drink and the amounts of urine you pass, to monitor this for a few days.
D) ‘Venflon’ cannula sited in an arm vein.
This is a route for any drugs which may need to be given into a vein. It avoids the need for injections. If the site becomes sore or inflamed please inform the nurses. After 3 or 4 days it will be taken out. W
LCN.
S
89
90
Date
lNTENSIVEANDCRITICALCARE NURSING Problem or potential problem
Nurse signature
Action
E) Possibility of constipation.
Lack of muscular movement whilst on bedrest, change in diet and side effects of some medications you may have been given, all predispose to constipation. It is normal not to have your bowels open for 3 days or longer in these circumstances. To prevent this from becoming a problem, a mild laxative will be given the day after admission or sooner if you require it. It is important to take the laxative as ‘straining’ to open your bowels can cause an excessive strain on the heart.
F) Possibility of pressure areas developing (i.e. reddened sore areas on buttocks, heels, elbows) due to bed rest.
Change your position in bed at frequent intervals, if you need help the nursing staff will assist.
G) Possibility of venous thrombosis (blood clot formation in a vein) as a result of reduced circulation due to bed rest.
Deep breathing and leg exercises will be advised by the physiotherapist and nursing staff (see separate sheet).
(vi)
Date
Problem or potential problem HI You may feel anxious due to a strange environment, equipment and uncertainty about your diagnosis.
Nurse signature
Action All equipment and tests will be explained to you and your family. Information regarding your diagnosis will be given to you by both medical and nursing staff. We are here to answer any questions you or your family may have, so please ask. (vii)
Problem or potential problem Possible need for a change in life-style
Nurse signature
Action Your risk of having a further heart attack will be assessed by looking at the factors which cause heart attacks. A tendency to coronary heart disease can be inherited, something which you cannot do anything about, but most other major causes of heart attacks are preventable, e.g. -
Smoking - 20 cigarettes a day doubles your risk of a heart attack. High blood pressure-this can also be inherited. Diet - high cholesterol (animal fats) Overweight.
Complete protection against having another heart attack cannot be guaranteed but the risk can be reduced by following advice on modifying your lifestyle. Risk factors
........
Recommendad
action..
(viii)
................
INTENSIVE
Date
AND CRITICAL
CARE NURSING
Nurse signature
Problem or potential problem
Action
J) Getting back to normal. Information and advice.
Gradually you will be able to return to your previous level of mobility. At first you will need to stay in bed although you will be able to sit in a chair for short periods. In approximately 2 or 3 days you will be transferred on to a general medical ward and you will be able to begin walking about-see separate sheet. The ward environment is quite different from the Coronary Care Unit. You will not require the same level of observation or attention from the nursing staff. Think of moving on to the ward as a step forward and a step nearer to going home. The usual time for discharge home is 7-10 days after admission. Most people return to work after 2-3 months. Relevant advice and leaflets will be given to you and your family, including information about ‘The Cardiac Rehabilitation Programme’ at Scarborough Hospital. If tests show you have not had a heart attack, you may be able to begin mobilizing sooner and be discharged home earlier. Relevant information and advice will be given to you. (ix)
General information Viiiting
Your family and close friends may visit at any time for short periods, except between 1 .OO- 2.30pm (rest period).
Boredom
Television, radio cassette, magazines and a few books are available - please ask. Newspapers are available on a daily basis.
Meal Times
Breakfast Lunch Tea/Supper
Nursing staff
One nurse will be allocated to be responsible for your care during your stay in the Unit. When this nurse is off duty, other coronary care nurses will care for you. If you have any questions, comments or complaints, please feel free to ask your nurse or the coronary care Sister.
8.00-8.30am 12.30-l.OOpm 6.00-6.30pm
You will be seen on a daily basis by a senior doctor and by the Consultant in charge of your treatment periodically during your stay in hospital. fx)
91
92
INTENSIVEANDCRITICALCARENURSINC
The care plan was devised in consultation with of the patients and staff. An evaluation effectiveness of the written information contained within it has taken place. A questionnaire was completed by 30 patients (see Fig. 3) of whom 100% were in favour of receiving written information about their care plan in the CCU. They indicated that they felt less anxious about their stay in the unit because of it. All the patients who completed the questionnaire wanted the care plan at the bedside for relatives and close friends to read, and thought it made them also less anxious about the care in the unit. The care plan is usually given to patients the day after admission or when they are well enough to read it, and is discussed with the primary nurse before it is left at the bedside.
Please tick appropriate
box.
1) Do you think it is helpful to have written information about your care in the Coronary Care Unit, or would you prefer just a verbal explanation? Verbal only 0 Verbal and written 0 2) Would you prefer not to have been given any of this information, either verbally or written, during your stay in the Coronary Care Unit? Would prefer not to be given the information Would prefer the information 0 3) Do You feel that having information you in this way has made you:
0
presented to
a) Less anxious about your care in CCU 0 b) More anxious about vour care in CCU 0 ci It has not affected yobr anxiety levels in either way Cl 4 Do you think the care plan/information sheet should be left at the bedside for your relatives or close friends to read?
Additional written information is given in the form of booklets relevant to the patient’s condition, with advice on medication and the cardiac rehabilitation programme, and videos are shown. Both structured and informal discussion with the patient and his family about the information documented in the care plan has proved an excellent means of communication and facilitates education of patients, junior staff and learners. Directing the written information to patients e.g. asking the patient to inform the nursing staff of any chest pain or discomfort however slight, and backing this up with the reasons why, reinforces the patients’ understanding of their condition, and creates an informal relaxed atmosphere where both patients and relatives feel free to ask questions and discuss problems at any time. Fortunately there is a cardiac rehabilitation sister based in CCU who takes referrals from primary nurses. When time, staffing and circumstances permit, the primary nurses are able to visit their patients at home with the rehabilitation nurse. We feel not only able to care for our patients’ physical needs, but that psychological care and rehabilitation is a top priority. In a busy unit with a large throughput of patients our philosophy of care and method of primary nursing ensures that very few patients ‘slip through the net’ and the majority receive support and advice from a coronary care nurse from hospital admission to discharge, and in the subsequent weeks at home.
Acknowledgements
Did they read it? If so did it make them: a) Less anxious about your care in CCU 0 b) More anxious about your care in CCU 0 c) Did not affect their anxiety levels either way 0 ANY FURTHER COMMENTS:
Fig. 3 Patient evaluation of the care plan/information sheet used in coronary care
I would like to thank Clare Garlick, Jeffrey Caunt for their encouragement this article.
Sue Malton and in the writing of
References Ahdellah F 1972 The nursing role in the Coronary Care System - In: Meltzer L E, Dunning A J Textbook of Coronary Care. Charles Press, Maryland pp 35-51 Ashworth P M 1985 Don’t forget to talk to them. Nursing Mirror 160 (18): 51-52
Ih'TENSIVEAND<:RITI~:AL(:ARENURSIN(; 93 Burke L E 198 I Learning and retention in the acute care setting - Critical Care Quarterly 4 (4): 67-73 Caunt J E 1987 The three minute mile. Senior Nurse 6 (5): 14-16 Chamberlain D A 1989 Thrombolysis in the treatment of acute myocardial infarction. Care of the Criticially III 5 (5): 180-181 Collaborative Croup 1988 ISIS 2 trial (Second International Study of Infarct Survival) Randomized trial of intravenous streptokinase, oral aspirin, both or neither amongst 17 187 cases of suspected myocardial infarction. Lancet 2: 349-60 Department of Health and Social Security (DHSS) Circular (1989) the extending role of the clinical nurse; legal implications and-training requirements. PUCMO (89) 7. PUCNO (89) IO Farrel J, Booth’ E,’ Hayburn T 1$85 Telling it straight. Nursing Mirror 160 (la): 51-52 GISSI trial 1986 Effectiveness of intravenous thrombolytic in acute myocardial infarction. Lancet 1 397-402 Glazier et al 1986 American Journal of Cardiology 586 (58): 667-672
Jowett N, Thompson D 1989 Introduction to coronary care. In: Comprehensive Coronary Care - Scutari Press, Harrow: p. 11 Joy M 1989 General management of the coronary patient - Care of the critically ill. 5 (5): 182-184 Kukin M et al 1990 Acute myocardial infarction, special care units, analgesia and complications. Current Opinion in Cardiology 5: 42 l-426 Meltzer L E, Pinneo R et al 1989 System of intensive coronary care - a manual for nurses. Charles Press, Maryland, pp 25-29 Reynell P C 1983 Self admission for myocardial infarction. British Heart Journal 49: 364-367 Thompson D 1987 Management of the patient with acute myocardial infarction. Nursing Standard 9 (4): 34-38 Townsend A 1988 Management of pain in patients with yi;crdial infarction. Intensive Care Nursing 4 (1): Willetts K 1989 Assessing 85 (4): 52-54
cardiac
pain.
Nursing
Times