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Nurses at Heart of Cardiac Care

Monday July 28, 2003
Roslyn M. Scriber (left), RN, manager of cardiology, and Kristin Sullivan, RN, BSN, reconnect hemodynamic monitoring in the post-procedure area at Our Lady of Lourdes Medical Center in Camden, NJ.
Photo by Frank Peluso Photography.
Roslyn M. Scriber (left), RN, manager of cardiology, and Kristin Sullivan, RN, BSN, reconnect hemodynamic monitoring in the post-procedure area at Our Lady of Lourdes Medical Center in Camden, NJ. Photo by Frank Peluso Photography.
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ACCORDING TO THE NATIONAL Vital Statistics Report, diseases of the heart remain the leading cause of death in the US as of 20001. While tremendous advances in cardiac procedures have decreased recovery time and improved outcomes, they don't change the fact that heart disease is still a frightening diagnosis for patients. Nurses must keep up with advances in cardiac care to ease that anxiety through patient education and attentive care.
Drug-Eluting Stents
Many procedures once reserved for the operating room now occur in the cardiac catheterization lab. At Our Lady of Lourdes Medical Center in Camden, NJ, catheterizations are performed both for diagnostic purposes and as interventions to correct problems. One of the newest procedures is the use of drug-eluting stents. Stenting itself is not new technology; however, the Sirolimus-covered stents used at Our Lady of Lourdes release the drug slowly into the artery wall to prevent overgrowth of tissue that causes restenosis. Lourdes has been using these new stents in combination with anticoagulants, such as aspirin or clopidogrel bisulfate (Plavix®), with good results since the FDA approved the stents earlier this year.
Nurses are integrally involved with the patient from the time they present through the cath lab procedures and discharge. Through questions about the patients' health history, their own knowledge, and interaction with family members, nurses find ways to meet patients at their level of understanding in both emergent and scheduled situations.
"The public is more medically minded now," says Roslyn M Scriber, RN, CCRN, manager of invasive cardiology at Lourdes. "Nurses have to be at the cutting edge of things." This can mean attending vendor inservices on new equipment or offsite conferences and seminars, where nurses can update their knowledge of the latest technologies. And at Our Lady of Lourdes, the nurses are required to pass annual competency exams.
During procedures, nurses circulate cases to monitor patients under conscious sedation, assist physicians, and help detect condition changes that need immediate intervention. Most cath lab nurses at Our Lady of Lourdes have critical care experience, with skills and training in treating the acutely ill. "Things do happen, do carry risks, and we need a team that can respond appropriately and efficiently," Scriber says.
After the procedures, nurses continue to be involved with the patient in the recovery area. Patients are frequently queried about the puncture site, their perception of how the procedure went, and whether they have additional questions or areas of concern. These interactions provide more opportunities for nurses to assess and teach patients.
Nurses take every opportunity to teach and reinforce good health habits. They emphasize smoking cessation and weight reduction. "If we're fixing them but are not educating them on what has contributed [to their condition] or what they can do to in order to decrease their risk, then we're not doing our job," Scriber says.
Brachytherapy, an alternative for treating in-stent restenosis, is used at Deborah Heart and Lung Center, Browns Mills, NJ. This technique involves the use of small doses of radiation to prevent a stent blockage from recurring. Jill Curlis, RN nurse manager, says patient instruction is a large part of the nurses' role. "We pride ourselves on patient education. We like to know that the patients clearly understand what is going to happen to them," she says. Frequent inservices on brachytherapy and other new procedures are provided to the nursing staff, so the nurses can help patients better understand their care.
Patients and families are involved in the educational component of care at Deborah. "Heart disease is very frightening to anyone," Curlis says. "We try to keep everyone involved." Education begins the minute a patient is admitted. "There is too much information to bombard patients on the day they're going home," believes Curlis. The multidisciplinary approach to patient care includes weekly meetings with the dietitian, case manager, physical therapist, respiratory therapist, physician, and nursing staff to review every patient on the unit.
Patients with newly diagnosed heart disease are often taken unaware, and nurses often are the first to recognize depression in their patients. "You feel life is never going to be the same once you hear something is wrong with your heart," says Curlis. Nurses identify patients who need additional information about how their life will be impacted by their condition. Most patients must make changes in their lifestyles, beginning with diet, exercise, and smoking cessation. "The nurses ... reassure them that life will get back to normal, and things will fall into place," Curlis says.
Nurses at the Surgical Forefront
Some patients still require operative repair for their disease. In the surgical arena, technical advances have brought patients - and the nurses who care for them - into an even more complex realm. Abington Memorial Hospital, Abington, PA, is doing a large number of minimally invasive cardiac procedures using methods that create shorter incisions and use small instrumentation. The results for patients are reduced time in the operating room, decreased discomfort, and less scarring.
V. Paul Addonizio, MD, chief of the Cardiac Surgery Division, believes that Abington's unique all-nurse team benefits him both during surgery and in the preop and postop phases of patient care. "We are ahead of the bell curve. It is a model for the future," says Addonizio.
Abington's nurses and nurse practitioners provide many of the services other healthcare facilities reserve for medical residents or physician assistants. Addonizio and his team have worked together for many years and have even developed surgical techniques and instruments for procedures they have introduced to Abington, such as homografting and valve repairs.
"It wouldn't be possible without the experience and skills of the nurses," says Addonizio. "We are more efficient and timely because we don't have to continually train residents to do procedures."
Nurses on Addonizio's team function as first assistants, scrubs, and circulating nurses. "It takes a lot of accountability. We have an active role that he depends very much on," says Heidi Keegan, RN, CCRN, cardiac clinical leader at Abington. Addonizio almost exclusively teaches the team's specialized operative training. "You need a full understanding of the severity and importance of what you're doing," Keegan says. Patients coming in are not always stable, she says, "so there isn't time to teach at every single instance."
Barbara Todd, MSN, CRNP, director of clinical cardiology at Abington, explains that the team model allows for better continuity and improved skill levels, which translates into better patient care. The NP sees patients from their initial contact with the cardiosurgical service, through testing and the procedure, during inpatient hospital care, and in postoperative outpatient follow-up. There are opportunities all along the way to educate the patient.
"The opportunity to meet the patient after the procedure is the best part," Keegan says. This is often not possible for general operating room nurses. But the Abington team takes tremendous pride in its involvement with these critically complex surgical patients. "We never go home without knowing they're OK," Keegan says.
Mary Shaw Miller, RN, BSN, is a contributing writer for Nursing Spectrum.
Minino A, et al. Deaths: Final Data for 2000. Nat Vital Stat Rep. September 16, 2002. Vol. 50, No. 15. Available at: www.cdc.gov/nchs/data/nvsr/nvsr50/ nvsr50_15.pdf. Accessed July 10, 2003.