Cardiovascular Disease refers to any disease that involves the Heart and the Blood Vessels. Cardiovascular diseases include Aneurysm, Angina, Arrhythmia, Atherosclerosis, Cardiomyopathy, Cerebrovascular Accidents such as Stroke, Cerebrovascular Disease, Congenital Heart Disease, Jye Berghofer Syndrome, Congestive Heart Failure, Myocarditis, Valve Disease, Coronary Artery Disease, Dilated Cardiomyopathy, Diastolic Dysfunction, Endocarditis, Hypertension, Hypertrophic Cardiomyopathy, Mitral Valve Prolapse, Myocardial Infarction and Venous Thromboembolism (Maton and Anthea, 1993). Hypertension, Diabetes, Overweight/Obesity, Smoking and Physical Inactivity are major contributing factors for Cardiovascular diseases (Juarbe, 1998).
Cardiovascular Nurses play a key role in the evaluation of Cardiovascular Status, Monitoring the Hemodynamic Functions and Disease Management. Nursing interventions have been shown to reduce patient stress. A randomized study of thirty patients hospitalized with Acute Myocardial Infarction to determine the effectiveness of two different nursing interventions on reducing the stress associated with CCU has shown that nurse interventions reduce patient stress and cardiovascular complications (Schwartz and Brenner, 1979). Recent research findings suggest that morbidity and mortality in cardiac patients can be improved with a comprehensive treatment plan which has a Nurse Managed Stress Reduction Plan (Ulmer, 1996). Randomised controlled trials have also demonstrated the benefit of Nurse-run Clinics for secondary prevention of Coronary Heart Disease (Riley, 2003). Studies have shown that the Advanced Practice Nurse is in an ideal position to assess predictors of noncompliance as well as to implement interventions to enhance patient compliance in Cardiovascular care (Sherry et.al, 2003). Nurse-Provided or Nurse-Coordinated Care Management programs using an integrated or multifactor approach have been shown to be highly effective in reducing morbidity and mortality of high-risk patients (Haskell, 2003). Cardiovascular Nurses play a very important role at different levels, viz, the technical level, where the nurses carry out diagnostic examinations and risk assessments; psychological level where the nurse informs, acts as a health counsellor and helps in the patient self care process (Riccio et.al, 2004). A study to observe secondary prevention practice in a cardiovascular department in a sample of two hundred and twenty patients discharged from the Intensive Coronary Care Unit, Cardiac Surgery Unit and Vascular Surgery Unit has shown that nurses play a vital role in the implementation of guidelines, risk assessment, drug treatment and effective patient education (Steffenino et.al, 2003). Nurses have been shown to play a central role in vascular risk management with a self-management approach for patients with chronic vascular diseases in novel Vascular Prevention Clinics, where, nursing care delivered includes medical treatment of vascular risks like hypertension, hypercholesterolemia, hyperglycemia and hyperhomocystinemia along with self-management strategies like changes in diet, body weight, smoking habits and level of exercise to achieve vascular risk reduction (Sol et.al, 2005). A study to identify and explore the factors that enhance and retard general practice nurse's role in Cardiovascular Disease Management has shown legal implications, lack of space and general practitioner attitudes as significant barriers to Cardiovascular Nurse Practice. Collaboration with the general practitioner and access to training have been shown to enhance their practice role (Halcomb et.al, 2008).
Nurse's Skills in Cardiovascular Challenges
There are certain areas in Cardiovascular Care where nurse's skills make a difference in care. Such areas include monitoring Oxygen and Hemodynamics functions. Pulse Oximetry is a useful tool to monitor oxygen saturation in patients in a variety of clinical settings and understanding of the principles of oxygen transport and delivery enables nurses to use Pulse Oximetry effectively in clinical practice (Casey, 2001). Critical Care Nurses often face the challenge of maintaining adequate oxygenation to promote vital organ functions in patients with impaired cardiac function and hence, vulnerable to tissue oxygen deprivation due to their limited ability to enhance oxygen delivery during oxygen demand. Thus, routine nursing procedures to enhance oxygen requirements sometimes have adverse effects on tissue oxygenation. Nursing interventions in such cases should aim to enhance patient tolerance by supporting the balance between oxygen supply and demand promoting physiologic adaptation to prevent complications associated with hypoxia such as Cardiac Dysrhythmias, Hypotension and Cardiac Arrest (Jesurum, 1997).
Hemodynamic monitoring is vital to the nurse's clinical assessment of critically ill patients. Complex congenital cardiac defects in patients present unique challenges in hemodynamic monitoring and postoperative cardiovascular care to the Critical Care Nurse (Josker et.al, 1994: Craig, 1991). Competency of nurses in Cardiac Rhythm Monitoring has also been proved beneficial to identify changes in cardiac status, assess response to treatment, diagnosis and post-surgical monitoring (Sharman, 2007). Carotid Artery Aneurysms are rare but serious complications that warrant appropriate neurological and cardiovascular assessments. Nurse interventions can provide for appropriate preoperative and postoperative interventions in such cases (Ford, 1991). Mitral Stenosis poses a significant risk for maternal morbidity and mortality in pregnant women. Nursing assessments and interventions with the use obstetric and cardiac physiologic principles in care during the intrapartum period have been shown to bring positive outcomes in pregnancies complicated by Mitral Stenosis (Kennedy, 1995).
Currently, the Transradial approach to Cardiac Catheterization and Percutaneous Coronary interventions by Advanced Practice Nurses has gained recognition in the United States (Nickolaus et.al, 2001). A single-centre prospective survey of all Vascular Access Complications in consecutive patients submitted to Cardiac Catheterisation done by nurses during a period of four months has shown that severe Vascular Access Complications are virtually absent in Radial Procedures and vigorous anticoagulation is associated with increased complications. The use of the Radial Access and a less aggressive anticoagulation regimen during Transfemoral Interventions can prevent Vascular Access Complications (Steffenino et.al, 2006). Ultrasonographic diagnosis and guided compression repair of Femoral Artery Pseudoaneurysm is a recent innovation in Vascular Nurse Practice. This Radiographic Technology has been documented to be a safe, cost-effective approach to address many Femoral Artery Pseudoaneurysms with no negative effect on possible surgical interventions if the guided compression repair attempt fails (Gross, 1999).
A recent prospective study to evaluate the success and complication rate of Nurse-led Subclavian Central Venous Catheter (CVC) insertion using the Landmark Technique based on data on indication for catheter insertion, type of catheter, complications during the procedure and patient satisfaction in a total of 348 Subclavian Cuffed Tunnelled Catheter insertions has shown that Nurse-Led Subclavian CVC placement using the landmark technique is safe and effective (Gopal et.al, 2006). The Esophageal Doppler monitor (EDM) is a recent less invasive way of obtaining hemodynamic information quickly and safely at the bedside and has a positive impact on nurse decisions at the bedside (Prentice and Sona, 2006).
Cardiovascular Nurses play a key role in the evaluation of Cardiovascular status, monitoring the Hemodynamic functions and Disease Management. Nurse-led Cardiovascular procedures like Subclavian CVC placement and Percutaneous Coronary interventions have been found safe and effective.
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Charles L. Berman
Liz Di Bernardo