CORONARY CARE UNIT
ROYAL UNITED HOSPITAL
BATH
STUDENT NURSE
PROGRAMME
NAME ………………………………….
DATE ……………
(Updated October 2012)
Welcome to the Coronary Care Unit at the Royal united Hospital NHS Trust.
The Cardiology department consists of the Cardiac centre, the Cardiac Ward,
Cardiac day case and the Coronary Care Unit. As a learner nurse you will have
the opportunity to spend time in all areas of the department. This will ensure
that you both observe and participate in care of patients throughout their stay
in hospital and have the chance to see diagnostic procedures.
The aim of the programme is to guide your learning with assistance from your
designated mentors and should be completed by the end of your placement. The
programme is practically orientated and enables you to acquire the knowledge
and skills to provide a high standard of care to cardiac patients. Your mentors
are available for teaching, advice and support and you will be given regular
feedback on your progress.
The key mentor for Coronary Care is Junior Sister Collette Bowers and she
should be your first contact if you have any problems or queries whilst being
placed on Coronary Care.
We operate a team approach to mentoring and you will be assigned to one of
these teams. Each team contains mentors and associate mentors. Please be
advised that only the mentors can sign off your paperwork.
Your off duty will follow a set rota. This is to try and balance the numbers on
each shift so that you can get the best possible support and teaching from your
mentors. If you need to change a shift then please try and swap amongst
yourselves. If you are still experiencing difficulties then please speak to the
key mentor (Collette Bowers).
We hope you enjoy your time on Coronary Care and look forward to working with
you.
The Cardiology Department
The Cardiac Centre
The Cardiac Centre is based on the third floor of RUH central. The staff base
consists of nurses and technicians. Patients attend as in or out patients for
exercise tolerance tests, echocardiogram including stress and trans-oesophageal
echocardiograms, tilt table test and 24-hour and 7 day ECG tapes. Patients
attend for insertion of permanent pacemakers and cardiac catheterisation which
may progress to percutaneous coronary intervention. Also there are Myoviews
and MUGAs that are carried out with the use of nuclear medicine.
The Coronary Care Unit (CCU)
The CCU is an eight bedded unit and includes a procedure room. Patients are
admitted from the Accident and Emergency Department, the Intensive Care
Unit, the Cardiac Ward or a general ward. Most patients are admitted with
acute myocardial infarction, unstable angina, acute heart failure, arrhythmias or
post cardiac arrest. Emergency procedures including temporary pacing,
pericardiocentisis and swann ganz (to name a few), are also carried out on the
unit.
The Cardiac Ward
The cardiac ward consists of 28 beds. Patients on the ward are transferred
from CCU, directly admitted from the Accident and Emergency department or
transferred from a general ward. The Cardiac Ward rehabilitates patients post
myocardial infarction and unstable angina and also cares for patients with a
variety of cardiac and medical conditions.
The Medical Day Case Unit
This contains 8 trolley/bed spaces. Patients are admitted to the day case area
from home. Day case receives patients who are to receive permanent
pacemakers, undergo elective cardioversion, cardiac catheterisation or other
investigations and for medication management.
Other professionals within the Cardiology Directorate
Cardiac rehabilitation - Trained members of staff and a secretary. The team
provides a comprehensive rehabilitation programme which is offered to all
patients post myocardial infarction. Patients are seen as inpatients and then
invited to attend an outpatient programme. This service now also extends to
patients post coronary artery bypass graft. There are also community
rehabilitation nurses who provide a similar community based service to patients.
Heart Failure Nurses – There is 1 part time nurse that is based in the hospital
who assists the medical and nursing staff in the clinical management of heart
failure patients. Part of the role is educating the patient and their families to
manage their condition at home and thus hopefully with early awareness of
symptoms, can avoid a hospital admission. They facilitate the discharge process
and liaise with the community heart failure team. They also have a key role in
end of life issues and ensuring this is addressed holistically.
Medical Staffing – Five Consultant Cardiologists : Dr Hubbard, Dr Mansfield, Dr
Carson, Dr Lowe and Dr Easaw; A Specialist Registrar and Clinical Fellow; Senior
House Officers - who rotate between being based on CCU and Cardiac Ward;
House officers who are based on the ward and are assigned to the Consultants.
Nurse Practitioner -The job has a vast spectrum of responsibilities some of
these include running the cardiology clinics, the main one being the rapid access
chest pain clinic.
Medical Nurse Practitioner for Cardiology- a trained member of nursing staff
who works as the bridge between the medical and nursing staff but does have a
more junior doctor role.
Be familiar with the Hospitals policies and procedures. These are all
available on the hospital intranet
Glossary of terms
ABG - arterial blood gas
ACS - acute coronary syndrome
AE – atrial ectopics
AF - atrial fibrillation
AMI - acute myocardial infarction
Angio - angiogram/ angiography
ASD - atrial septal defect
BIPAP – Bi-level positive airway pressure
CABG - coronary artery bypass graft
CCF - congestive cardiac failure
CPAP - continuous positive airway pressure
CVP - central venous pressure
Cx – circumflex
ECG - electrocardiogram
Echo - echocardiogram
EPS - electrophysiological studies
ETT - exercise tolerance test
IABP – intra-aortic balloon pump
ICD - implantable cardiac defibrillator
IHD - ischemic heart disease
INR - international normalised ratio
LAD – left anterior descending
LMS – left main Stem
LVF - left ventricular failure
NSF - national service framework
NSTEMI – non ST elevation myocardial infarction
PEA - pulseless electrical activity
PCI – percutaneous coronary intervention
PPCI – primary percutaneous coronary intervention
PPM - permanent pacemaker
RCA – right coronary artery
Rt-PA - tissue plasminogen activator
STEMI – ST elevation myocardial infarction
TNK - tenecteplase
TOE - trans-oesophageal echocardiogram
TPW - temporary pacing wire
VE - ventricular ectopic
VF - ventricular fibrillation
VSD - ventricular septal defect
VT - ventricular tachycardia
Routine
Coronary care has four shift patterns:
Early – 7:00 to 15:00
Late – 13:00 to 21:00
Long Day – 7:00 to 21:00
Night - 20:45 to 7:15
Nursing handovers take place in the staff room and are usually at the beginning
of the early, late or night shift. They begin promptly and staff should make
sure that they are ready at the start of the shift to receive the handover. This
is a general handover about all the patients currently on CCU. The nurse coordinating the shift then allocates patients to each nurse. The student will work
alongside one of their mentors and if a mentor is not available another trained
member will be allocated. When students have settled into their roles they
maybe asked to take a patient themselves with supervision and support form a
trained member of staff. A more detailed handover about the allocated
patients is then received at the bedside from the nurse on the previous shift.
Medications are given out at approximately 8:00, 14:00, 18:00 and 22:00 or as
required.
Observations, the frequency of which should be dependent on the patient’s
condition, but in general they are taken at 7:00, 10:00, 14:00, 18:00 and 22:00.
This should include heart rhythm, heart rate, blood pressure, oxygen
saturations, respiratory rate and to include early warning scores (EWS).
Patients are allowed to wake naturally in the morning before observations are
taken.
Routine electrocardiograms, if necessary, should be performed before the ward
round. They should be taken on the first three days of admission to CCU, every
third day and when a patient has pain, a rhythm change or their condition alters.
Always ensure a trained member of staff has seen the ECG prior to it being
filed in the patients notes.
Ward rounds take place at approximately 9:00 every morning. You should
report any symptoms, concerns, and side effects of medications to the medical
team. The patient’s medical notes, medication charts and blood results should all
be available for the medical staff to review. Ensure that you understand if
there are any changes to treatment and if further tests are required. Record
changes to care on handover sheet and establish if patient is medically fit for
transfer to another ward.
Meal times are at 8:00, 12:00 and 17:00. When the HCA is on duty she will
make the breakfasts and fill in the menus for the day. Additional drinks are
offered as required as well as mid-morning, mid-afternoon, at 20:00 and prior to
settling if time permits. The water jugs are replaced at 6:00 and 18:00. The
total drank from the jug is recorded at these times rather than individual
glasses of water.
Patients are offered a wash in the morning depending on their condition and
individual needs. This can be offered before or after the ward round as time
allows or the patient chooses. If the patient prefers to wait until the afternoon
then this choice is respected.
The phlebotomist will visit the CCU in the morning to take routine bloods.
It is the responsibility of all staff to ensure, daily, that the unit is kept clean,
tidy, well stocked and that all equipment is in working order.
During the night shift the arrest trolleys and defibrillators should be checked
by an ILS/ALS provider. Controlled drugs and the blood glucose monitoring
equipment should also be checked on a daily basis.
The cups and jugs are washed and the tea trolley prepared for the morning.
Fluid balance charts are totalled at 6:00.
It is the shift co-ordinators responsibility to ensure a new handover sheet is
completed for the morning.
Break times are allocated by the shift co-ordinator. However, it is up to the
individual nurse to ensure that they have taken their breaks. You are allocated
15 minutes coffee break and 30 minutes meal break during the day and 1 hour at
night.
Other Information:
A pain assessment tool is used to assess the level of pain and response to
analgesia. This tool is the scale of 1- 10, 10 being the worst pain.
Admission/discharge document should be fully completed along with MRSA
swabs within 24 hours of admission.
All patients should have a patient profile, peripheral venous cannula care record
and appropriate integrated care pathway and/or care plans. It is the
responsibility of all staff that the paperwork is completed. Students should
ensure that the paperwork is countersigned by a trained member of staff.
It is the responsibility of all staff to maintain the upkeep of equipment. Any
faulty equipment should be cleaned, labelled and sent for repair as soon as
possible. Equipment should not routinely be loaned to other departments. If
equipment is loaned then it should be recorded on the board (Ward, type of
equipment, mems number and date of loan).
Please keep the nurse in charge informed of any changes to your patient’s
condition or treatment. The nurse in charge is always available for advice and
support.
A member of the nursing staff should hold the drug keys at all times.
If you cannot attend your placement for any reason i.e. sickness, please inform
the unit and UWE as soon as possible.
Rotation
During your placement on CCU, you will spend 1 week in the cardiac centre and
cath lab. A timetable will be devised for you. This is an opportunity for you to
gain a wider knowledge of Cardiology and maybe achieve competencies that may
not be achievable in the CCU environment. If you have any problems whilst in
these other areas speak firstly to the staff concerned or if this is problematic
then raise your concerns with the key mentor.
Learning achievement whilst in coronary
care Unit. You will aim to be competent/confident in:
Signature
Using bedside and
central monitors
Using all documentation
Handing over patient to
next nurse on duty
Caring for a patient
after a myocardial
infarction
Caring for a patient with
ACS
Caring for a patient with
pericarditis
Caring for a patient with
left ventricular failure
In referring patients to
other members of the
multi-disciplinary team
In full assessment of a
patient including
pressure sore prevention
and manual handling
In planning care for a
patient
In care of a patient
after death
In escorting patients for
investigations
In using:
NIBP
Thermometers
Pulse oximeter
In principles and
practicalities of blood
Date
glucose monitoring
In obtaining specimens:
Midstream urine
Sputum
Stool
In care of a cannula and
administration of
intravenous fluids
In preparing a bed space
for a patient
Observe and participate
in the admission of a
patient
Observe and participate
in the transfer of a
patient to a general ward
Observe a cardioversion
Understand:
Signature
The procedure for
obtaining patient notes
The procedures for
patient transfer to
another hospital
The procedure for
discharging a patient
home
The issues of consenting
patients for procedures
The procedure for
patient self-discharge
Date
CARDIAC ARREST
Signature
Date
Be familiar with the
procedure for cardiac
arrest
Be familiar with the
cardiac arrest rhythms
Understand the
difference between
shockable and nonshockable rhythms
Be competent in basic
life support
Observe and if possible
participate in a cardiac
arrest
Become familiar with the
contents of the arrest
trolley and there use
If appropriate, and you are willing, you will be encouraged to participate in a
cardiac arrest usually by doing some basic life support skills e.g. Chest
compressions.
Cardiac arrests can be stressful. Please reflect with a member of staff after
witnessing any cardiac arrest or stressful event that you may witness
ELECTROCARDIOGRAM
Assessment: Taking a 12 lead ECG
Criteria:
The activity will demonstrate the learner’s ability to:
• accurately and safely perform a 12 lead ECG
• understand the principles behind taking a 12 lead ECG
Criteria to be
achieved.
(The candidate
can...)
explain why it is
necessary to
take an ECG
Rationale
to establish the rhythm
to establish if pain is cardiac in origin
to provide clinical evidence for diagnostic
purposes
explain when an
ECG should be
taken
explain to the
patient the
task, why it is
being taken and
gain verbal
consent
help the patient
to the correct
position in a
safe manner
on admission
when having chest pain
if condition deteriorates/changes
pre and post thrombolysis
routine morning ECG (day 1-3) and every
3rd day
must legally obtain informed consent
aware of safe manual handling techniques
ensures optimal reading
ensures good contact between skin and
contact = less electrical artifact
clean and
prepare the
skin
Achieved
apply the 10
electrodes and
leads in the
correct place
to ensure correct reading from both
vertical and horizontal planes
minimise
electrical
artefact
check lead placement
ensures they are not pulling or lying over
each other
asks the patient to relax and lie
motionless
check
calibration
correctly label
the ECG and
file in notes
inform medical
staff (if
appropriate) or
someone
competent at
ECG
interpretation
to enable interpretation using a standard
recording
useless without a name, date and time and
reason for performing it
Student Nurse
Cardiology Workbook
The Heart
• Label the diagram below:
Blood flow through the heart
Fill in the blanks:
The heart receives ____________ blood from the ________
and ________ ____ ____ into the right ______. Blood is
then passed through the ________ valve into the right
_________. Blood is then pumped through the _________
valve into the left and right _________ ________ and out to
the lungs where it becomes __________. Blood returns to
the left side of the heart via the _________ _____ into the
left ______. From the left ______ blood flows through the
______ valve into the left _________. The left _________
then pumps blood to the body up through the ______ valve and
into the _____.
Complete with these words
Atrium, ventricle, tricuspid, aortic, mitral, ventricle,
inferior, oxygenated, deoxygenated, pulmonary, aorta,
pulmonary veins, ventricle, atrium, vena cava, superior,
atrium and pulmonary arteries.
The Conduction system
• Label the diagram below:
The Conduction system
Fill in the blanks:
The ____-_____ node acts as the heart’s _________. It is
controlled by the autonomic nervous system and fires an
impulse which spreads across the ______ and ____ ______
causing them to depolarise and contract. The impulse then
reaches the _____-___________ node where it is _____
allowing the _____ to empty fully. After this, the impulse
passes to the ______ of ___ and down the right and left
______ ________ into the ________ fibres. This causes
the __________ to depolarise and contract. The heart then
repolarises ready to start the cycle again.
Complete with these words
Pacemaker, sino, right, atrial, bundle, ventricular, left, atrio,
held, branches, bundle, atria, his, ventricle and purkinje.
The normal ECG complex
If the above cycle of depolarisation and repolarisation occurs
then this will produce a normal ECG complex which is known as
sinus rhythm. The diagram on the following page represents a
normal sinus rhythm complex.
The Normal ECG complex
P – wave = spread of the impulse from SA (sino-atrial) node
through myocardium (heart muscle) of both atria causing atrial
depolarization and atrial systole (contraction).
QRS – complex = spread of impulse through both ventricles
causing ventricular depolarization and ventricular systole.
T –wave= ventricular diastole (relaxation) and repolarisation of
the heart muscle.
PR –interval= the time taken for the impulse to travel from the
SA node to the AV node and bundle of his.
ST –segment= the time between the end of the impulse and
diastole.
Interval
PR
ST
QT
QRS
Time in seconds
0.12 – 0.20
0.27 – 0.33
0.35 – 0.42
0.08 – 0.11
Determining cardiac rhythm
When analyzing a heart rhythm, the following should always be taken
into consideration:
♥ Is the rhythm regular or irregular?
♥ Calculate the heart rate.
♥ Are there any P waves?
♥ Are there any QRS complexes?
♥ Is there one QRS complex for every P wave?
♥ Are the intervals normal?
Coronary Circulation
Familiarize yourself with the following coronary arteries and what
parts of the heart they supply blood to:
●Right coronary artery
●Left main stem which bifurcates into the:
-Left anterior descending
-Left Circumflex
Monitoring the patient
Colour the dots!
(Remember - ride your green bike!)
Coronary Artery Disease
Pathophysiology
Coronary Atherosclerosis
This disease is characterised by an accumulation, in the vessel
walls, of lipids, complex carbohydrates, blood and its products,
smooth muscle cells, calcified deposits and fibrous tissues.
The uptake of these substances causes an atheromous plaque
which alters the function and structure of the artery leading
to a reduction in blood flow to the myocardium.
Atherosclerosis probably begins with fatty streaks which
are commonly found within the artery’s intima of young people
and have even been detected in the aorta at birth. The
interactions between the arterial wall and blood constituents
then result in atherosclerosis. The endothelium,
monocytes/macrophages, smooth muscle cells, platelets and
blood lipids all play an important role.
The endothelium (inner layer of arterial wall) has a layer
of metabolic active cells which acts as a selective barrier
between blood and the arterial wall. It can generate
vasoactive substances and gives the artery a surface which is
not conducive to thrombus formation. This is due to the
release of prostacyclins and heparin sulphate. These cells can
also produce growth factor and a chemical which helps the
underlying smooth muscle to relax. If the endothelium loses
its integrity then these protective factors are compromised
and the atherosclerotic process is aided in its progression.
Macrophages come from circulating monocytes (type of
white blood cell). The monocytes adhere to the compromised
endothelium and migrate to the sub-endothelial layer where
they become macrophages. Macrophages then ingest and
degrade oxidised low-density lipoproteins (LDL) (the bad
cholesterol). LDL can then be taken up into the artery wall.
Macrophages also encourage connective tissue proliferation
and are a source of foam cells within the fatty plaque.
Consequently, they play a major role in the atherosclerotic
process and plaque formation.
Smooth muscle cells are normally found in the tunica
media (middle layer) of the artery wall. However, they become
a problem when they migrate to the tunica intima (inner layer)
of the artery. Once migration has occurred instead of
primarily being involved in contraction they take on secretory
functions and respond to growth factors which allow them to
proliferate. In advanced plaques they accumulate lipids and
form foam cells.
Platelets not only form thrombus which is a complication
of atherosclerosis but have a role in plaque formation. When
platelets are activated they stimulate virtually all cell types
within the plaque and release vasoconstrictor substances along
with growth factors.
Lipids form the main components of most plaques. They
affect the endothelium, smooth muscle and macrophages and
stop them from functioning normally. The artery wall takes up
the lipids in a chemically altered form and when LDL is
modified it becomes irresistible to monocytes. Macrophages
will only digest LDL in a modified form.
The atheroma may be big enough to narrow the lumen of
the artery. Plaques composition varies dramatically from
plaques with a pool of cholesterol and a thin fibrous cap to
those which are solid. They are most commonly found where
arteries bend or branch.
Risk Factors
There are several risk factors that increase the chances of
atherosclerosis. Can you name nine of them?
♥
♥
♥
♥
♥
♥
♥
♥
♥
Other factors have been shown to increase risk.
♥ Alcohol and coffee - heavy drinking leads to hypertension
and drinking more than six cups of coffee a day has also
been linked
♥ Homeostatic factors - recently those with high levels of the
clotting factor VII and fibrinogen have shown to have
increased risk
♥ Insulin resistance - those who are not diabetic but need a
higher amount of insulin to regulate glucose levels (usually
linked to obesity and lack of exercise)
Tasks
The following tasks are designed to direct your learning on CCU.
1. Read through both articles from the Nursing Standard on
Myocardial Infarction and see if you can do the quizzes at the
end.
2. Design a care plan for a patient admitted with cardiac chest
pain.
3. We use a number of different medications on CCU. Try and
find out the actions of these classifications of drugs and their
side effects:
a. Beta blockers
b. ACE I inhibitors
c. Nitrates
d. Anti-platelets
e. Lipid lowering
f. Anti-coagulants
g. Anti-arrhythmics
h. Thrombolytics/ Fibrinolytics
i. Diuretics
j. Inotropes
4. For each of the above drug classifications name two
medications regularly used.
5. Drugs that affect the clotting mechanism of blood are used
routinely on CCU e.g. heparin, tirofiban. Find out about the
clotting cascade so that you can understand the mode of action
of these drugs
Notes