2. Objectives
Explain the cardiopulmonary bypass process.
Describe five key assessment areas in the early postoperative
period.
Discuss causes of postoperative hypotension in a cardiac
surgery patient, and assessments and interventions for same.
Use the nursing process framework for managing of a post
operative thoracic surgery patient
5. Patient selected for CABG
Angina that cannot be controlled by medical therapies
Unstable angina
Positive exercise tolerance test and lesions or blockage that
cannot be treated by PTCA
Older
Have more advanced coronary diseases
Have more impaired left ventricle function
Complication from or unsuccessful PTCA
To decrease the mortality associated with bypass surgery, it is necessary to
consider
Urgency of operation
Age
Previous heart surgery
Sex
Left ventricle ejection fraction
Percentage stenosis of the left main coronary artery with greater than 60%
The number of major coronary arteries
6. Advantages and disadvantages of Using the Internal Mammary
Artery for Myocardial Revascularization
Advantages
Improved short- and long-term patency rates over saphenous
vein grafts
Diameter close to diameter of coronary arteries
Aortic anastomists not required
Internal mammary artery retains its nervous system
innervations and thus has the ability to adapt size to provide
blood flow according to myocardial demands
No leg incision if only internal mammary artery used
Vascular endothelium adapted to arterial pressure and high
flow, resulting in decreased intimal hyperplasia and
atherosclerosis
May be used as a free or sequential graft with good results
7. Disadvantages
Dissection of internal mammary artery takes longer, resulting in
longer cardiopulmonary bypass time, but this depends on
surgeon’s experience.
Extensive dissection may increase risk of postoperative bleeding.
Pleural space is entered, so pleural chest tube is required
postoperatively.
Postoperative pain may be increased because of entry into pleural
space and extensive dissection.
Use of bilateral internal mammary arteries can increase the risk of
infection and sternal dehiscence, especially in diabetic
patients.
8. Preoperative Teaching About the Intensive Care Unit Experience for the
Patient Undergoing Cardiac Surgery
Equipment to Point Out
Cardiac monitor
Arterial line
Thermodilution catheter
IV lines and IV infusion pumps
Endotracheal tube and ventilator
Suctioning
Explain how to communicate when intubated; unable to talk
Explain when extubation can be anticipated
Foley catheter (increased sensation to urinate)
Chest tubes (anticipated removal)
Pacing wires
Nasogastric tube
Soft hand restraints
9. Incisions and Dressings to Expect
Median sternotomy or other incision
Leg incision (if saphenous vein is used)
Patient’s Immediate Postoperative Appearance
Skin yellow owing to use of Betadine solution in operating room
Skin pale and cool to touch because of hypothermia during surgery
Generalized “puffiness,” especially noticeable in neck, face, and
hands, because of third spacing of fluid given during
cardiopulmonary bypass
Awakening From Anesthesia
Patient recovers in the intensive care unit (ICU); does not go to the
post anesthesia care unit
Each patient recovers from anesthesia differently Patient may feel
certain sensations
Patient may hear certain noises
Patient may be aware or able to hear but unable to respond
10. Discomfort
Amount of discomfort to be expected
When pain might be expected
Relief mechanisms
Positioning/splinting
Medications
Patient-controlled analgesia (PCA) and the importance of
early administration of pain medication
Postoperative Respiratory Care
Turning
Use of pillow to splint median sternotomy incision
Effective coughing and deep breathing after extubation; have
patient practice exercises before surgery
Incentive spirometry
Early mobilization
11. Nursing Responsibilities in Caring for the, Cardiac Surgery
Patient in the Immediate
Postoperative Period
Priority Interventions Performed by the Critical Care Team
on Arrival
Attach patient to bedside cardiac monitor and note rhythm.
Attach pressure lines to bedside monitor (arterial and
pulmonary artery); level and zero transducers and note
pressure values and waveforms.
Obtain cardiac output/index and note existing inotropic or
vasoactive drips.
12. Check peripheral pulses and perfusion signs. Connect
ventilator and auscultate breath sounds bilaterally.
Apply end-tidal carbon dioxide (ETCO2) device to ventilator
circuit and note waveform and value (best indicator of
endotracheal tube placement).
Apply pulse oximetry device to patient and note SpO2 value
and waveform.
Monitor chest tubes and character of drainage: amount,
color, flow. Check for air leaks.
Measure body temperature and initiate rewarming if
temperature <96.8 F (36 C).
13. Once the Patient Is Determined to Be Hemodynamically
Stable
Measure urine output and note characteristics.
Obtain clinical data (within 30 minutes of arrival).
Obtain chest radiograph.
Obtain 12-lead electrocardiogram (ECG).
Obtain routine blood work within 15 minutes of arrival; tests
may include ABGs, potassium, glucose, PTT, hemoglobin
(varies with institution).
Assess neurological status.
Test pacemaker function by assessing capture and sensing.
14. Examples of Nursing Diagnoses and collaborative
problems for
Cardiac Surgery Patients
1.Decreased Cardiac Output related to changes in
left ventricular preload, afterload, and contractility
2.Decreased Cardiac Output related to cardiac
dysrhythmias
3.Impaired Tissue Perfusion related to
cardiopulmonary bypass, decreased cardiac output,
hypotension
4.Impaired Tissue Perfusion related to
microembolization secondary to the surgery process
15. 5.Impaired Gas Exchange related to cardiopulmonary
bypass, anesthesia, poor chest expansion, atelectasis,
retained secretions
6.Ineffective thermoregulation realted to inection or
post pericardiotomy cyndrome
7.Impaired Comfort related to endotracheal tube,
surgical incision, chest tubes, rib spreading
8.Anxiety related to fear of death, intensive care unit
environment
9.Risk for Fluid Volume Deficit related to abnormal
bleeding
10.Risk for Infection related to surgical procedure,
invasive lines, drainage tubes, hypoventilation, retained
secretions
16. 11.Deficient knowledge about self care activities
12.Acute pain related to surgical trauma and
pleural irritation caused by chest tubes and
graft site
13.Disturbed sensory perception related to
excessive environmental stimulation and sleep
deprivation (post cardiotomy psychosis)
17. Complications:
I. Cardiac complications
Preload alteration
Hypovolemia
Persistent bleeding
Cardiac tamponade (may decrease preload of the heart by
preventing available blood from entering the heart)
Fluid overload
Afterload alteration (the force that the ventricle must
overcome to move blood forward. Vascular resistances and
alteration in body temperature are the most common causes
in Afterload alteration after cardiac surgery)
2. Hypothermia
3. Hypertension
18. 4. Heart rate alteration
Tachydysrhythmias
Bradycardia
Dysrhythmias may or may not affect cardiac output
5. Contractility alteration
Cardiac failure
Myocardiac infarction
II.Pulmonary complications
Impaired gas exchange
III.Neurological complications
Cerebrovascular accident
IV. Pain
19. V. Renal Failure and electrolyte imbalance
Renal failure
Acute tubular necrosis
Hypokalemia
Hyperkalemia
VI. Other complications
Hepatic failure
Coagulopathies
infection
20. Recovering From Cardiac Surgery
General Instructions
Avoid lifting heavy objects (10–15 lbs or more) for first 3 months.
Avoid strenuous arm movement such as golf or tennis. When getting in
and out of chair or bed, use legs. Arms should not bear weight and should
be used only for balance.
Do not drive for 6 weeks after surgery. (May ride in automobile.)
Follow physician’s instructions for activity progression.
Resume sexual activity when you can climb two flights of stairs without
stopping (with physician’s recommendations).
Use alternative positions for 3 to 4 months to decrease stress on sternum;
avoid side-lying and prone positions.
Inspect and cleanse surgical incisions daily with soap and water.
Understand medications, including reason for taking, dosage, frequency,
and side effects.
Follow dietary restrictions.
Understand how much pain to expect and how to manage it.
21. Risk Factors
Follow instructions on individual risk factors, their impact on
health after cardiac surgery, and how to modify them.
Seek referrals as appropriate (e.g., for a weight loss program
or a smoking cessation program).
Follow-up With Physician
Know how and when to schedule follow-up appointments.
Be alert for signs and symptoms of infection, such as fever,
increased redness, tenderness, drainage, or swelling of
incisions.
Report palpitations, tachycardia, or an irregular pulse (if
normally regular) to the physician immediately.
Seek follow-up care if you experience dizziness or increased
fatigue, sudden weight gain or peripheral edema, shortness of
breath, or chest pain.
