Page 249 - ACCCN's Critical Care Nursing

226 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

term, risk may accumulate. Patients with angina are ● communicating with patients and families, while
encouraged to attend cardiac rehabilitation programs to reducing conversation demands as excessive conversa-
learn how to deal with symptom management. 41 tion by patients may unnecessarily raise heart rate 45
● restricting the number and type of visitors in the acute
Angiotensin-converting enzyme (ACE) inhibitors have
been recommended for all post-AMI patients while in hos- phase is customary, but many patients feel safer if a
pital, with review of prescription at 4–6 weeks postdis- family member is present
charge. Patients with left ventricular failure should be ● provision of comprehensive information to families,
maintained on ACE inhibitors. Similarly, diuretics provide with more concise information in understandable
the mainstay of the management of left ventricular failure language for patients.
if it is present (see Chapter 19). Diabetic patients have a Nurses need to monitor patients for signs of excessive
higher mortality after AMI in both acute and long-term anxiety, including facial expressions and behavioural
phases. Provision of an insulin-glucose infusion for BSL changes. However, overt behaviours may be controlled by
>11 mmol/L during the acute phase, followed by subcutane- the patient, so careful conversation and/or use of specific
ous injections for at least 3 months, has been demonstrated assessments may be necessary to detect anxiety. The move
to significantly reduce mortality up to 3 years post-AMI. 42 to the step-down or general ward may also be stressful to
Transfer to a step-down unit or general ward usually occurs the patient and family. This move needs to be planned
when the patient is pain-free and is haemodynamically and discussed, and promoted as a sign of recovery.
stable. Stability means that patients are not dependent on
IV inotropic or vasoactive support and have no arrhyth- Cardiac rehabilitation
mias. Discharge home after AMI varies, but usually occurs Coronary heart disease is a chronic disease process, which
at day 3 for low-risk patients. 18 often presents with acute events such as ACS or AMI. Like
all chronic illnesses, it has implications for patients in
Independent Practice terms of lifestyle change, uncertainty of long-term out-
Emotional responses and patient comes, functional changes and social and economic
and family support alterations. Cardiac rehabilitation aims to address these
issues. The World Health Organization describes cardiac
ACS or AMI is usually accompanied by feelings of acute rehabilitation as ‘the sum of activities required to influ-
anxiety and fear, as most patients are aware of the signifi- ence favourably the underlying cause of the disease, as
cant threat posed to their health. For many patients it well as to ensure the patients the best possible physical,
18
may also be the first experience of acute illness and asso- mental and social conditions so that they may, by their
ciated aspects such as ambulance transport, emergency own efforts, preserve, or resume when lost, as normal a
care and hospitalisation, so they may experience shock place as possible in the life of the community’. Systematic,
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and disbelief as well. Fast-track processes require patients individualised rehabilitation and secondary prevention
and their families to process a large amount of informa- need to be offered to all AMI patients. Participation in
tion and make decisions quickly, and this, added to an well-structured, multidisciplinary programs has been
alien environment, full of unfamiliar technology and per- demonstrated to reduce mortality by up to 30%. Addi-
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sonnel, can be quite distressing. However, the environ- tional benefits have been shown for improvements in
ment can also promote a feeling of security for patients exercise tolerance, symptoms, serum lipids, psychological
and their families. Patients’ perceptions of the CCU envi- wellbeing and cessation of smoking. 48-50
ronment have been linked to recovery. 43
Cardiac rehabilitation is structured around four phases,
Anxiety is a common response to the stress of an acute beginning with phase I, during admission. The compo-
50
cardiac event and leads to important physiological and nents of phase I include:
44
psychological changes. The sympathetic nervous system
is stimulated, resulting in increased heart rate, respiration ● information regarding the disease process, the prog-
and blood pressure. These responses increase the workload nosis, and an optimal approach to recovery, early
of the heart and therefore myocardial oxygen demand. mobilisation and discharge planning
In an acute cardiac event, these demands occur when ● assessment of patients’ understanding of their diagnosis
perfusion is already poor and may lead to worse out- and treatment as a foundation for self-management
comes, including ventricular arrhythmias and increased ● discharge planning which incorporates discussions on
myocardial ischaemia. Therefore, staff working in emer- adaptation to the functional and lifestyle changes
gency and coronary care should employ strategies to needed for secondary prevention – dietary intake of
reduce a patient’s anxiety. lipids, exercise, smoking cessation, stress management
and symptom monitoring, and management of acute
Increasing a patient’s sense of control, calm and confi- symptoms
dence in care reduces the patient’s sense of vulnerability, ● early mobilisation as an inpatient to encourage a
44
whether it is realistic or not. This can be achieved by: positive approach to recovery with monitoring of
● providing order and predictability in routines, allow- the response to activity in heart rate, shortness of
ing the patient to make choices, providing informa- breath and chest pain to determine the rate of prog-
tion and explanations, and including the patient in ress. (Most hospital units use an activity progress
decision making chart for this purpose based on metabolic equiva-
● using a calm, confident approach lents [METs]).