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Cardiac Surgery
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

B. Percutaneous Transluminal Angioplasty:
(PTCA)

Intracoronary Stenting
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
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
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.
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
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
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
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.
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).
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.
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
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
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)
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
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
V. Renal Failure and electrolyte imbalance
Renal failure
Acute tubular necrosis
Hypokalemia
Hyperkalemia
VI. Other complications
Hepatic failure
Coagulopathies
infection
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.
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.

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Cardiac Surgery.ppt

  • 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
  • 3.  B. Percutaneous Transluminal Angioplasty: (PTCA)
  • 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.