INTERDISCIPLINARY CLINICAL MANUAL Policy and Procedure

Transcription

1 INTERDISCIPLINARY CLINICAL MANUAL Policy and Procedure TITLE: Management of Angina in NUMBER: Effective Date: January 2014 Page 1 of 6 Applies To: Interdisciplinary Clinical Manual Cardiac Rehabilitation Program (Inclusive of Hearts in Motion) THIS IS A MEDICAL DIRECTIVE FOR REGISTERED NURSES, WORKING IN THE OUTPATIENT CARDIAC REHABILITATION PROGRAM AND REQUIRES ASSESSMENT OF COMPETENCY PRIOR TO PERFORMING. THIS IS A POST-ENTRY LEVEL COMPETENCY FOR DIETITIANS WORKING IN THE OUTPATIENT CARDIAC REHABILITATION PROGRAM AND REQUIRES ASSESSMENT OF COMPETENCY PRIOR TO PERFORMING THIS IS A BASIC LEVEL COMPETENCY FOR PHYSIOTHERAPISTS WORKING IN THE OUTPATIENT CARDIAC REHABILITATION PROGRAM

2 Management of Angina in Page 2 of 6 POLICY 1. The Registered Nurse working in the ilitation Program performs the medical directive components of policy (administration of NitroGLYcerin, Oxygen, and ASA) as outlined in the following procedures only after successfully completing the competency requirements as follows: 1.1. Reviewing this policy/procedure 1.2. Experience working with the cardiac patient population for a minimum of 6 months 1.3. Being deemed competent to perform following appropriate preceptorship/orientation by a qualified Registered Nurse Following appropriate assessment of the patients description of symptom s suggestive of angina (Refer to Procedure #1). 2. The Registered Nurse is to perform and document the self-assessment of competency on an annual basis, including a review of this policy and procedure. 3. The Dietitian working in the ilitation Program performs the Post-entry level competency (assessment of angina/assessment of blood pressure) only after successfully completing the competency requirements as follows: 3.1. Reviewing this policy/procedure 3.2. Successful completion of the learning module for Blood Pressure Monitoring During Stress Test (CC ) Following appropriate assessment of the patients description of symptom s suggestive of angina (Refer to Procedure #1) 4. The Dietitian is to perform and document a self-assessment of competency on an annual basis, comprised of reviewing this policy and procedure, and the learning module for Blood Pressure Monitoring During Stress Test (CC ). 5. In the event of medical emergencies requiring immediate assistance, the Health Care Professional (HCP) working in the ilitation Program (Registered Nurse, Physiotherapist, and Dietitian) calls DEFINITIONS Primary Cardiac Rehabilitation: Designed for patients who have no documented cardiac disease but have significant risk factors for developing cardiac disease. Secondary Cardiac Rehabilitation: Designed for patients who have documented cardiac disease.

3 Management of Angina in Page 3 of 6 GUIDING PRINCIPLES AND VALUES 1. The Cardiac Rehabilitation Program is comprised of both primary and secondary programs The Hearts in Motion program (currently located at Mumford Road, Cobequid and Dartmouth Sportsplex) is for patients who have either primary or secondary cardiac disease The Mumford Road location is primarily a hospital program directed towards patients with secondary cardiac disease only. 2. Patients attending the outpatient Cardiac Rehabilitation Program will have a completed Cardiac Rehabilitation Referral. 3. In the event symptoms suggestive of angina are experienced, patients will be quickly and consistently managed by following the Management of Angina Medical Directive. 4. The Cardiac Rehabilitation Program is staffed: 4.1. Monday to Thursday by Registered Nurses, Physiotherapists, and Dietitians who provide both the exercise and education components of the program On Fridays by Physiotherapists and Dietitians who provide only the educational component of the program Should a client experience symptoms of angina during the educational component, refer to Procedure Statement #3. Note: A registered nurse has to be available prior to an exercise class being held. 5. When a patient is referred to the Cardiac Rehabilitation program, the initial visit is for purposes of assessment by the RN, Physiotherapist and the Dietitian and determination of appropriateness for the program. At each subsequent visit, the patient is asked for an update to determine if there has been any change in condition from the last visit. PROCEDURE 1. If the patient experiences symptoms suggestive of angina, the HCP assesses the patient for the following:: 1.1. chest, arm or jaw pain, 1.2. diaphoresis and/or pallor, 1.3. feeling weak or short of breath,

4 Management of Angina in Page 4 of indigestion, 1.5. nausea 1.6. blood pressure and pulse 2. Registered Nurse Scope of Practice Statement The following is a Medical Directive for the Registered Nurse which requires assessment of competency prior to performing Verifies information from the health record regarding whether the patient is currently prescribed NitroGLYcerin for angina Based on the findings from Procedure 2.1, administers /or instructs the patient to take NitroGLYcerin SUBlingual for one dose, when the patient has a systolic blood pressure greater than 90 mm HG Note: If the patient does not have their own supply of NitroGLYcerin with them, offer the patient NitroGLYcerin SUBlingual from a stock supply. Symptoms Unresolved Following One Dose of NitroGLYcerin 2.3. If symptoms do not resolve following the initial dose of NitroGLYcerin, administer/ instruct the patient to take NitroGLYcerin SUBlingual every 5 minutes to a maximum of 3 doses for treatment of angina when the patient: is experiencing ongoing symptoms suggestive of angina has a systolic blood pressure greater than 90 mm HG 2.4. Administer 3 Litres/min supplemental oxygen via nasal prongs concurrently with SUBlingual NitorGLYcerin when the patient has a BP greater than 90 mm HG Administer 3 Litres/min supplemental oxygen via nasal prongs when the patient has symptoms of angina and systolic BP is less than 90 mm HG. Note: Do not administer SUBlingual NitroGLYcerin at any time if the BP is less than 90 mm HG. Symptoms Resolved 2.6. If symptoms resolve with less than 3 SUBlingual NitroGLYcerin direct the patient to resume exercise at lower pace if appropriate At the next class, assess the patient to determine general feeling of wellness, whether there has been additional discomfort, or need to take additional SUBlingual NitroGLYcerin since the last class If no adverse signs and symptoms as per Statement attempt resumption of usual exercise level If symptoms resolve after 3 SUBlingual NitroGLYcerin, but no other adverse findings, (symptoms or patient expresses feeling unwell), advise the patient to stop not continue the exercise that day and re-evaluate at a subsequent session.

5 Management of Angina in Page 5 of 6 Note: The patient may stay for the education portion if desired. Symptoms Unresolved 2.8. If angina is unrelieved after SUBlingual NitroGLYcerin and/or supplemental oxygen, or the patient condition deteriorates, contact 911 EMS for transport to the Emergency Department While awaiting EMS, consider giving the patient 160mg ASA to chew, after verifying that: the patient is not allergic to ASA or has no obvious contraindication to taking ASA if a known asthmatic, the patient has a history of previous use of ASA with no adverse effects the patient does not have current active bleeding (GI or other bleeding disorders) There is no history or evidence of head injury within the past 24 hours The patient agrees to take the ASA 3. Physiotherapist or Dietitian When the Registered Nurse is not available Scope of Practice Statement The following is a Basic Competency for the Physiotherapist and a Post-Entry Level Competency for the Dietitian which requires assessment of competency prior to performing. Refer to Policy Statements # 3 and # Verifies information from the health record regarding whether the patient: is currently prescribed nitroglycerin for angina has had the appropriate education about angina & treatment with nitroglycerin, & is accustomed to taking nitroglycerin prior to activity 3.2. Assesses the patient as per Procedure Statement # Assist / instruct the patient to take their own nitroglycerin every 5 minutes to a maximum of 3 doses when the patient has a systolic blood pressure greater than 90 mm HG 3.3. If angina is unrelieved after 3 SUBlingual nitroglycerin or if the patient condition deteriorates, contact 911 EMS for transport to the Emergency Department If symptoms resolve after 1 or 2 SUBlingual NitroGLYcerin, but no other adverse findings, (refer to procedure statement # 2.7) the patient may choose to remain for the education session; consult with the RN regarding staying for exercise that day. 4. Notification/Consulting Physician(s) 4.1. Notify the following when patients are sent to the Emergency Department: Program Director or Delegate

6 Management of Angina in Page 6 of Referring Physician or Specialist 4.2. If concerned that patient condition is changing but patient is otherwise stable, instruct patients to see their family doctor to arrange follow-up with their cardiologist (referring physician) as appropriate. 5. Documentation 5.1. Document in the patient s health record the symptoms experienced by the patient and the actions taken by the HCP. REFERENCES Editors: Sinz, Elizabeth & Navarro, Kenneth. Advanced Cardiac Life Support. (2011) Heart & Stroke Foundation of Canada. Heart and Stroke Foundation of Canada, Recovery Road: An Information Guide for Heart Patients and Their Families, page 75, Preparing for Emergencies. Printed from site December 5, B136CE6C95BF%7D/recovery-road-en.pdf RELATED DOCUMENTS Policies CC Blood Pressure Monitoring During Stress Test * * *