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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 2  |  Page : 70-79

Effect of intervention guidelines on nursing performance regarding patients with angina


Medical Surgical Nursing Department, Faculty of Nursing, Zagazig University, Zagazig, Egypt

Date of Submission17-Jul-2019
Date of Acceptance04-Aug-2019
Date of Web Publication5-Dec-2019

Correspondence Address:
Eman A Metwaly
Medical Surgical Nursing, Faculty of Nursing, Zagazig University, Zagazig 44519
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_4_19

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  Abstract 


Background The primary threat of angina is the higher probability of being exposed to cardiac arrest if not detected and diagnosed in time. If any type of angina is left ignored and untreated, it can lead to myocardial infarction at any stage thereafter.
Aim To evaluate the effect of intervention guidelines on nursing performance regarding angina patients.
Research design A quasi-experimental design was used to achieve the aim of the study.
Setting The study was conducted in Cardiac Care Unit at Zagazig University Hospitals, Sharkia, Egypt.
Patients and methods A convenient sample of 30 nurses working at CCU was recruited.
Tools of data collection Two tools were used: a structured interview questionnaire, and an observational checklist.
Results There was a lack in nurses’ knowledge about angina before intervention guidelines, with mean±SD of 1.1±0.30, which increased in postintervention and follow-up phases of intervention guidelines, with mean±SD of 1.96±0.18, with a statistically significant difference (P=0.000). Moreover, there was a lack in nurses’ practice before intervention guidelines, with mean±SD of 1.13±0.35, which increased in postintervention and follow-up phases of intervention guidelines, with mean±SD of 2.00±0.00 and 2.00±0.00, respectively, with a statistically significance difference (P=0.000).
Conclusion Based on the results of the study, mean scores of nurses’ knowledge and practice were higher in postintervention and follow-up phases of nursing intervention guidelines.
Recommendation Nurses should be trained firstly before they are allotted to working in CCU mainly to understanding how to deal with angina cases.

Keywords: angina, intervention guidelines, nurses’ performance


How to cite this article:
Sakr MD, Metwaly EA, Taha NM. Effect of intervention guidelines on nursing performance regarding patients with angina. Egypt Nurs J 2019;16:70-9

How to cite this URL:
Sakr MD, Metwaly EA, Taha NM. Effect of intervention guidelines on nursing performance regarding patients with angina. Egypt Nurs J [serial online] 2019 [cited 2020 May 29];16:70-9. Available from: http://www.enj.eg.net/text.asp?2019/16/2/70/272394




  Introduction Top


Coronary heart disease (CHD) is the most common cause of death in the developed nations and is one of the leading causes of illness burden in developing nations. There were 7.3 million deaths owing to CHD worldwide in 2001. Three-fourths of global deaths occurred in the low-income and middle-income nations. The rapid increase in CHD burden in most of the low-income and middle-income nations is owing to socioeconomic changes, increase in life span, and acquisition of lifestyle-related risk factors. The CHD mortality rate, however, varies significantly over the developing nations (Gaziano et al., 2010).

Stable angina is characterized by episodes of pain or discomfort in the chest, jaw, arms, shoulder, back, or epigastric region, especially after a heavy meal. It is usually brought on by physical effort. Some patients have no pain but experience shortness of breath. Unstable angina may result in pain or discomfort at rest. A small number of people are affected by silent ischemia, and they may experience pain or discomfort once, with no further episodes (Blanchard and Murnaghan, 2010). Patients with diabetes are at risk to this, and it is vital that they attend regular diabetes checks so that their cardiovascular state can be checked. The degree or severity of disease does not always mean that a person has worse angina with severe disease or vice versa; therefore, newly reported angina must be reviewed in a secondary care cardiology setting (Conway and Fuat, 2007).

Primary prevention is the medical treatment of risk factors to prevent occurring of a cardiac incident, such as hypertension and high cholesterol where other risk factors exist (smoking, family history, or diabetes). Secondary prevention drug therapy will be given to patients with a diagnosis of CHD such as, antiplatelet therapy, ACE inhibitors, and lipid-lowering drugs (Fox et al., 2006).

Treatment of angina includes medical therapy which helps to reduce symptoms and prevent cardiovascular complications such as myocardial infarction and stroke. Guidelines on stable angina give us recommendations on which medications should be prescribed. Lifestyle changes are a key aspect of treatment of angina, specifically within the areas of diet, exercise, smoking, diabetes, hypertension, and psychological issues (Bellchambers et al., 2016).

The coronary care unit concept was, and remains, highly dependent on the expertise of nurses working in close collaboration with medical colleagues. From the early days of the coronary care unit, there has been recognition of the value of nurses developing specialist knowledge and skill in, for example, ECG interpretation, the understanding of treatment of acute myocardial infarction complications, and expertise in CPR. The formative years of the coronary care unit provide the earliest examples of nurses taking on ‘advanced’ roles (DiCenso et al., 2010).

Nurses are expected to play a basic role in health promotion through delivering health education to patients and the general population. Cardiac knowledge is not solely about anatomy and physiology but also entails patients’ self-management skills, medications, risk factors, exercise, stress, and diet (Hart et al., 2011). Nurses should be updated with information, regardless of their grade, skills, and experience, so as to be able to modify patients’ misconceptions about their condition and educate them about suitable lifestyle changes (Chow et al., 2017).


  Significant of the study Top


Atherosclerotic coronary artery disease (CAD) usually causes unstable angina/non-ST segment elevation myocardial infarction, which is associated with risk of cardiac death. Nursing intervention guidelines during acute attack are aimed at maintaining adequate tissue perfusion and relieving pain, including oxygen administering, assessment and checking of vital signs and ECG patterns, auscultation of heart and lung sounds, and prompt administration of nitrates and narcotic analgesics as needed. Rest and cessation of all activity should occur until pain subsides. The nurse should provide suitable positioning and supportive calm reassurance to reduce anxiety (Siebens et al., 2007). These intervention guidelines will provide assistance and increase awareness among the nurses who care for these patients.


  Aim Top


The aim of the study was to evaluate the effect of intervention guidelines on nursing performance regarding patients with angina in CCU at Zagazig University Hospitals through the following objectives:
  1. Assess nurses’ knowledge and practice regarding angina.
  2. Design and implement intervention guidelines based on assessment needs.
  3. Evaluate the effect of intervention guidelines on nurses’ knowledge and practice regarding angina.


Research hypotheses

  1. Mean score of nurses’ knowledge will be higher in postintervention and follow-up phases of intervention guidelines than before intervention.
  2. Mean score of nurses’ practice will be higher in postintervention and follow-up phases of intervention guidelines than before intervention.



  Patients and methods Top


Research design

A quasi-experimental research design was used to achieve the aim of the study.

Setting

The study was conducted in Cardiac Unit in Cardiac and Thoracic Hospital and Cardiac Unit at Internal Medical Hospital, Zagazig University Hospitals.

Sample

A convenience sample of 30 nurses working at cardiac care unit in cardiac and thoracic hospital and internal medical hospital was recruited.

Two data collection tools were used:

Tool I: A structured interview questionnaire (pre/post and follow-up test) was developed in a simple clear Arabic language by the researchers based on literature review (Arbour and Gélinasa, 2010; Sundström et al., 2016; Shim and Hwang, 2017) and experts’ opinions in light of relevant references to assess nurses’ knowledge regarding angina. It consisted of three parts:
  • First part: demographic characteristics of the studied nurses such as age, sex, marital status, level of education, years of experiences, and training courses.
  • Second part: nurses’ knowledge regarding angina, which consisted of 20 multiple-choice questions about definition of angina, prevalence, causes, risk factors, types, signs and symptoms, effects of angina on physical, psychological, and social health status, effects nutrition on occurrence of angina, effects of angina on sleep pattern, diagnosis of angina, and complications.
  • Third part: Nurses’ knowledge regarding treatment and care of patients with angina, which consisted of 24 multiple-choice questions about principles of angina management, type of angina treated at home, when the patient should go to the hospital during attack, clinical diagnosis of patients with angina on admission, nursing actions during angina attack according to priority, different methods of angina management, physical activity used in treatment of angina, patient’s position during attack, medications used in treatment of angina, methods of nitroglycerin administration, adverse effects of medications, therapeutic regimen, prevention of risk factors, nursing care of patient with angina during and after attack, and guidelines about cardiac rehabilitation,


Scoring system

For the knowledge, a correct answer was scored as one and an incorrect answer as zero. The scores were totaled and converted into a percentage score. A nurse who achieved 80% or higher total score was considered to have satisfactory knowledge, and those with lower scores had unsatisfactory knowledge based on statistical analysis.

Tool II: An observational checklist (pre/post and follow-up test) was used to assess nurses’ practice regarding angina. It was adopted from Pfisterer et al. (2010); Smith and Johnson (2014); and Lippincott (2015). It included most procedure carried out in the study which consisted of 9 parts with 103 items. It included four items for preparing patient on admission, 15 items for obtaining venous blood, 12 items for intravenous drug administering, 17 items for oxygenation, nine items for pulse oximetry, nine items for assessing pain, 10 items for sublingual medication, 16 items for ECG, and 11 items for cardiac monitoring.

Scoring system

For the practice, an item correctly performed was scored as one and incorrectly as zero. The scores were totaled and converted into a percentage score. A nurse who achieved a total score of 80% or higher was considered to have satisfactory practice, whereas those with lower scores were deemed to have unsatisfactory practice based on statistical analysis.

Content validity and reliability

Once the tools of data collection were prepared, their face validity and content validity were ascertained by a panel of three experts (two professor of medical surgical nursing and one professor of emergency medicine), who revised the tools for clarity, relevance, applicability, comprehensiveness, and ease of implementation. The agreement percentage was between 80 and 100%. In light of their assessments, minor modifications were applied. The reliability of the observational checklists showing reliability with a Cronbach’s α coefficient (r=0.97).

Description of the intervention

Procedure

The study was conducted in three phases (preparatory phase, implementation phase, and evaluation phase).
  1. The preparatory phase:
    • The researcher checked on the related materials and literature broadly. Assessments of the nurses’ knowledge and practice were made. Intervention guidelines were developed by the researcher. Detected needs, requirements, and deficiencies were translated to aims and objectives of the intervention guidelines. Moreover, teaching materials were prepared, that is, audiovisual materials on heart and coronary artery anatomy, areas that are susceptible to block by blood clotting, atherosclerosis, and treatment modalities.
  2. The implementation and evaluation phase:
    • Data were collected at Cardiac Care Unit of Cardiac and Thoracic Hospital and Internal Hospital at Zagazig University Hospitals during the period from June 2017 to May 2018.The researcher approached the responsible nursing supervisors as well as the responsible physician of determined areas daily to identify the number of newly admitted patients who were suspected to have angina. Selected nurses were met on daily bases for monitoring, in addition to the allocated assessment times before and after intervention guidelines.
    • The tools were filled through interviewing. The purpose of the study was explained to the nurses before answering the questions. The study was carried out in the morning and afternoon shifts every day. At initial interview, the researcher introduce herself to initiate line of communication, explain the purpose of intervention guidelines, and fill out the structured interview questionnaire (tool one) to assess nurses’ knowledge before implementation of intervention guidelines, and the researcher filled out the observation checklist (tool two) to assess nurses’ practice before implementation of intervention guidelines. The researcher scheduled with them the teaching sessions for both theory and practice, and the nurses were divided into small groups; each group included 3–4 nurses. Teaching has been implemented for nurses in terms of sessions and teaching on the spot during their official working hours.


Nursing intervention guidelines consisted of two parts:
  1. The first part: Theoretical part:
    • It included data related to anatomy of the heart and blood vessels, coronary arteries, functions of the heart, coronary artery diseases, angina pectoris: definition, causes, risk factors, signs and symptoms, types of angina, diagnosis, nursing action to relieve angina attack according to priority in admission and cardiac care unit, therapeutic and surgical treatment, dietary instructions, prevention of risk factors, important drugs related to angina, exercises, and cardiac rehabilitation.
    • For theoretical contents, teaching sessions were conducted; each session takes from 15 to 30 min. The number of sessions was five sessions for each group (3–4 nurses) to acquire the related information. Each nurse was supplemented with the knowledge booklet, and utilized each session to ensure understanding and clear any misconception or misunderstanding. The researcher continued to reinforce the gained information, answer any raised questions, and gave feedback. Communication channel was kept open between the researcher and the study group subjects. Then, immediately after intervention, knowledge test was carried out, and then follow-up test was carried after 3 months.
  2. The second part: the practical part:
    • It included items related to how to prepare patient on admission, obtaining venous blood, intravenous drug administering, oxygenation, pulse oximetry, assessing pain, sublingual medication, ECG, and cardiac monitoring. For practical contents, each nurse’s performance regarding the predetermined procedure was evaluated before provision of any data (pretest) utilizing the defined checklists (second tool). Then patients were divided into the small groups (3–4 nurses in each group). Teaching sessions were conducted; each session took from 30 to 45 min. Demonstrations and redemonstration were carried on 10 sessions for each nurse. Manual booklet was given to each, and the immediate postintervention test was done. Theoretical part was achieved in the head of the department office and practical part in clinical area. Teaching methods were lectures, small group discussion, and problem-solving situations. Teaching aids were utilized, including posters, videotape, handouts, and pen and paper test. The setting was equipped and prepared to be used. Follow-up test was done after 3 months.


Pilot study

A pilot study was carried out on five nurses to test for clarity, relevance, comprehensiveness, understandable, feasible, applicability, and ease of implementation. The results of the data obtained from the pilot study helped in modification of the tools; items were then corrected or added as needed. Nurses who participated in the pilot study were excluded from the main study sample.

Administrative design

An official permission was obtained from the Research Ethics Committee at the Faculty of Nursing and from the director of Zagazig University Hospital before conducting the study. Additional oral consent was taken from the nurses who participated in the study after explaining its purpose.

Ethical considerations

The ethical research considerations in this study included the following: the research approval was obtained before the intervention, the objectives and the aims of the study were explained to the participants, the researcher confirmed the confidentiality of participants, and participants were allowed for participating or not, and they had the right for withdrawing from the study at any time without penalty.

Author contribution

The first author contributed to the conception of the research, development of tools, statistical analysis, commentary on the tables, translation of the tools and booklet into Arabic, participated in the references and data collection, and administered the intervention. The second author contributed to the sample collection; provided the preintervention, postintervention, and follow-up tests; applied the intervention to nurses; preparation of videos, color brochure, and posters; participated in data collection; participated in reference collection and analysis of data; and administered the intervention. The third author contributed to development of tools, statistical analysis, participated in data collection and applying intervention.

Statistical analysis

Collected data were coded, computed and statistically analyzed using statistical package of social sciences (SPSS in Armonk, New York) version 22. Qualitative variables were presented as frequency and percentages. χ2 was used for comparison of categorical variables and was replaced by Fisher exact test if the expected value of any cell was less than 5. Quantitative continuous variables were presented as mean±SD if they were normally distributed, and Paired t-test was used for comparison. Quantitative continuous variables were presented as minimum to maximum and media if they were not normally distributed, and Wilcoxon signed rank test was used for comparison. The difference was considered significant at P value up to 0.05.


  Results Top


[Table 1] shows that 93.3% of studied nurses were aged less than 40 years, with mean±SD of 29.23±6.7 years. Moreover, 86.7% of them were married and did not receive any training courses about angina. In addition, 60.0% of them had done BSc nursing, and 73.4% of them had less than 10 years of experience.
Table 1 Percentage distribution of demographic characteristics of studied nurses (n=30)

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[Table 2] illustrates that there was a statistical improvement of nurses’ knowledge and their practice about angina in postintervention and follow-up phases of intervention guidelines, with a statistically significant difference (P=0.000).
Table 2 Studied nurses’ knowledge scores regarding angina throughout the study phases of intervention guidelines (n=30)

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[Table 3] mentions that there was improvement of nurses’ practice regarding admission, obtaining venous blood, intravenous drug administering, oxygenation, pulse oximetry, assessing pain, sublingual medication, ECG, and cardiac monitoring in postintervention and follow-up phases of intervention guidelines, with a statistically significance difference P=0.000.
Table 3 Studied nurses’ practice scores regarding angina throughout the study phases of intervention guidelines (n=30)

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[Table 4] shows that there was a statistically significant relation between nurses’ age, education level, years of experience, and attending training courses and their total satisfactory knowledge score about angina.
Table 4 Relation between demographic characteristics of studied nurses’ and their total satisfactory knowledge score about angina throughout the study phases (n=30)

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[Table 5] clarifies that there was a statistically significant relation between nurses’ age, education level, years of experience, and attending training courses and their total satisfactory practice score about angina.
Table 5 Relation between demographic characteristics of studied nurses’ and their total satisfactory practice score regarding angina throughout the study phases (n=30)

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[Table 6] shows that there was a strong positive correlation between total satisfactory knowledge and total satisfactory practice of studied nurses about angina in postintervention and follow-up phases of intervention guidelines, with a statistically significant difference (P=0.041 and 0.02, respectively).
Table 6 Correlation coefficient between total satisfactory knowledge, total satisfactory practice of studied nurses throughout the study phases of intervention guidelines (n=30)

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  Discussion Top


Angina pectoris is a disease characterized by reduced blood flow in coronary artery. If the patient reports pain, the nurse should direct the patient to halt all activities and sit or rest in a semi-fowler’s position to decrease the oxygen requirements of the ischemic myocardium.

The results of this study showed that the most of studied nurses aged less than 40 years. Moreover, most studied nurses were married and did not receive any training courses about angina. Approximately three-quarters of the studied nurses had less than 10 years of experience.

This result was in accordance with Taha (2017) who reported in a study entitled ‘Impact of a Designed Teaching Protocol about Nursing Management of Coronary Artery Bypass Grafting on Nurse’s Knowledge, Practices and Patient’s Outcome’, that the age of most nurses ranged from 20 to 40 years and were married. Moreover, more than half of them had less than 10 years of experiences, and the majority of them had no in-service training courses. This finding disagrees with Hamed (2009) who stated in unpublished master thesis entitled ‘Nurses performance during cardiopulmonary resuscitation in Intensive Care Unit and Cardiac Care Unit at Benha University Hospital’ that less than half of the nurses had experience in the range of 2–4 years.

Regarding level of education, two-thirds of the studied nurses had done BSc nursing. This could be owing to the increase in the number of graduates from Faculties of Nursing who are mostly working in intensive care departments. This was in accordance with Mohammed (2016), who clarified in a published study titled ‘Assessment of Nurse’s Knowledge and Practice Regarding Care of Patients with Acute Coronary Syndrome in Elmak Nimer University Hospital’ that most of study group had bachelor’s degree and most of them working in CCU.

This study showed unsatisfactory level of nurses’ knowledge before implementing nursing intervention guidelines showed. This deficiency in knowledge is owing to one or more of the following reasons, lack of orientation program before work; lack care conferences during work; nonavailability of procedure books; especially prepared for the critical care areas; and lack of direction and nurses’ appraisal about patient care. In agreement with these study findings, Sheta (2006), stated that many continuing education program evaluations use a comparison of the participant’s pretest and post test scores as an indicator of that program’s effectiveness. This in line with Ahmed (2013) who mentioned in unpublished master thesis titled ‘Developing nursing care standards for patient with disectomy at Assuit University Hospital’ that cardiosurgical nursing care requires nurses with particular knowledge and attributes. In addition, it is no longer possible to function effectively in these areas without updated knowledge and expertise and without acceptable personal and professional attitudes.

The result of this study illustrates that there was a statistical improvement in mean knowledge scores of the studied nurses in postintervention and follow-up phases of implementing nursing intervention guidelines. In this respect, Ahmed et al. (2015), mentioned that nurses must be able to expand their knowledge of this area through ongoing education, journals, and seminars. Subsequently, teaching programs for nursing staff constitute an imperative part. These programs are critically outlined to assess nursing staff in developing and enhancing the skills needed to provide high standards of care to their patients.

Regarding nurses’ practice, there was a significant improvement in practice scores of the studied nurses in postintervention and follow-up phases of implementing intervention guidelines. These results may clarify that preparation of intervention guidelines was successful in achieving better information and practice levels between nurses. Therefore, the course was successful in improving nurses’ knowledge and practice, which could be attributed to the structure, content, and process of the intervention guidelines. On the same line, Ahmed et al. (2015), revealed great improvement in the level of nurses’ practice after implementing nursing care standards in all items. This has been concluded by the presence of significant differences between results of before and after implementation of nursing care standards. This finding indicates that skills can be easily improved, especially if linked with their relevant scientific base of knowledge. Moreover, this result is in accordance with Nezamzadeh et al. (2012), who mentioned that nursing guidelines were effective in improving quality of nursing care.

Moreover, this result agrees with El-Metwally (2012) who stated in unpublished doctorate thesis entitled ‘Effect of educational program on the performance of nurses working with coronary artery bypass grafting patients at Cardiac Care Unit at Nasser Institute Hospital’ that most of the nurses had inadequate practice at the pre-program phase. This deficient practice revealed among this study nurses before implementation of the program is certainly linked to the previously mentioned low level of satisfactory knowledge among them. This is agreement with Drew and Krucoff (2010) who have indicated that practical procedures are best learned by instruction and closely supervised repeated practice while treating critical ill patients. After implementation of the study training program, statistically significant improvements were revealed in nurses’ practice at the postprogram phase. Overall, all the participating nurses had adequate practice at the postprogram phase. In this respect, Utriyaprasit et al. (2010), reported an improvement in nurses’ practice after the attendance at continuing nursing education sessions. Research findings indicated that continued nursing education programs increase both knowledge and performance.

Regarding the relation between demographic characteristics and nurses’ knowledge, this study revealed that there was a statistical significant relation between nurses’ age, education level, years of experience, and attending training courses and their total satisfactory knowledge score about angina. This was in line with Abd Elhamid (2011) who clarified that there was a highly significant statistical difference between nurses’ characteristics, namely, educational level, hierarchical level, and years of experience and their knowledge.

Regarding the relation between demographic characteristics and nurses’ practice, this study found that there was a statistically significant relation between nurses’ age, education level, years of experience, and attending training courses and their total satisfactory practice score about angina. This was in contrast with Abd Elhamid (2011) who showed that there was no statistically significant relation detected between nurses’ characteristics, namely, age, marital status, educational level, hierarchical level, and years of experience and their level of practice. Moreover, the result does not agree with Abd Elmoaty (2009) who revealed that there was no statistically significant correlation detected between practice level and experience.

Regarding the relation between total nurses’ knowledge score and their total practice score regarding care of angina patient, it was found that there was a strong positive correlation between total satisfactory knowledge and total satisfactory practice of studied nurses about angina in postintervention and follow-up phases of intervention, with a statistical significant difference. This finding might be owing to the effectiveness of applied intervention guidelines in improving nurses’ knowledge that reflected on their practice. This result agrees with Abd Elhamid (2011) who mentioned in unpublished master thesis in medical surgical nursing entitled ‘Assessment of nurses performance regarding angina attack patients in Emergency Unit at Mansoura University Hospitals’ that there was a highly significant difference between nurses’ level of practice and their knowledge regarding care. This is in line with Abd Elmoaty (2009), who clarified in unpublished master thesis at Ain Shams University entitled ‘Nurses’ Performance in caring for patients with cardiac arrest’ that there was a highly statistically significant relation between nursing knowledge and practice level.


  Conclusion Top


Based on the results of the study, mean scores of nurses’ knowledge and practice were higher in postintervention and follow-up phases of intervention guidelines than preintervention phase, which might mean an effective intervention guidelines.

Recommendation

Nurses should be trained firstly before they are allocated to working in CCU, mainly to understanding how to deal with angina cases. There should be increase in the period of nurses working in CCU (rotation period) for several months to improve nursing awareness about care of angina patient. With more research done on nursing care in cardiac care unit and encouraging personnel to use evidence-based guidelines, increase in the quality of nursing care can be reached.[27]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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