NURSING PROCESS: THE PATIENT AWAITING CARDIAC SURGERY
The cardiac surgery patient has many of the same needs and requires the same perioperative care as other surgical patients. The patient and family are experiencing a major life crisis. The association of the heart with life and death intensifies their emotional and psychological needs. Patients frequently are ad-mitted the same day as the procedure. For these patients, the nurse must prioritize needs carefully; in the time allowed, the nurse focuses on the needs that have the highest priority.
Before surgery, physical and psychological assessments establish the baselines for future reference. The patient’s understanding of the surgical procedure, informed consent, and adherence to treatment protocols are evaluated. Helping the patient to cope, understand the procedure, and maintain dignity are nursing responsibilities.
The preoperative phase of cardiac surgery begins before hos-pitalization. The nurse assesses the patient for other disorders, such as diabetes, hypertension, and respiratory, gastrointestinal, and hematologic diseases, and documents their treatment.
The nurse clarifies how the medication regimen is to be al-tered before surgery, such as tapering corticosteroids and digoxin, decreasing or discontinuing anticoagulants, and maintaining med-ications for treatment of blood pressure, angina, diabetes, and dysrhythmias. The nurse also clarifies the need to maintain activ-ity patterns, a healthy diet, healthful sleep habits, and cessation of smoking to minimize the risks of surgery.
Patients with nonacute heart disease may be admitted to the hos-pital the day of or the day before the surgery. Most of the pre-operative evaluation is completed before the patient enters the hospital. Many surgeons’ offices or hospitals mail an informa-tion packet to the patient’s home.
A history and physical examination are performed by nursing and medical personnel. A chest x-ray, ECG, laboratory tests, blood typing and crossmatching, and autologous blood donation (pa-tient’s own blood) may also be performed. The health assessment focuses on obtaining baseline physiologic, psychological, and social information. The patient’s and family’s learning needs are identi-fied and addressed as necessary. Of particular importance are the patient’s usual functional level, coping mechanisms, and support systems. These are important because the support of the family or significant others will affect the patient’s postoperative course and rehabilitation. Discharge plans are influenced by the lifestyle de-mands of the home situation and the physical environment of the home.
The preoperative history and health assessment should be thor-ough and well documented because they provide a basis for post-operative comparison. A systematic assessment of all systems is performed, with emphasis on cardiovascular functioning.
Functional status of the cardiovascular system is determined by reviewing the patient’s symptoms, including past and pres-ent experiences with chest pain, hypertension, palpitations, cyanosis, breathing difficulty (dyspnea), leg pain that occurs with walking (intermittent claudication), orthopnea, paroxys-mal nocturnal dyspnea, and peripheral edema. Because alterations in cardiac output can affect renal, respiratory, gastrointestinal, in-tegumentary, hematologic, and neurologic functioning, a history ofthese systems is also reviewed. The patient’s history of major ill-nesses, previous surgeries, medication therapies, and use of drugs, alcohol, and tobacco is also obtained.
A complete physical examination is performed, with special em-phasis on the following:
· General appearance and behavior
· Vital signs
· Nutritional and fluid status, weight, and height
· Inspection and palpation of the heart, noting the point of maximal impulse, abnormal pulsations, and thrills
· Auscultation of the heart, noting pulse rate, rhythm, and qual-ity; S3 and S4, snaps, clicks, murmurs, and friction rub
· Jugular venous pressure
· Peripheral pulses
· Peripheral edema
The psychosocial assessment and the assessment of the patient’s and family’s learning needs are as important as the physical exam-ination. Anticipation of cardiac surgery is a source of great stress to the patient and family. They will be anxious and fearful and often have many unanswered questions. Their anxiety usually increases with the patient’s admission to the hospital and the immediacy of surgery. An assessment of the level of anxiety is important. If it is low, it may indicate denial. If it is extremely high, it may in-terfere with the use of effective coping mechanisms and with pre-operative teaching. Questions may be asked to obtain the following information:
· Meaning of the surgery to the patient and family
· Coping mechanisms that are being used
· Measures used in the past to deal with stress
· Anticipated changes in lifestyle
· Support systems in effect
· Fears regarding the present and the future
· Knowledge and understanding of the surgical procedure, postoperative course, and long-term rehabilitation
The nurse allows adequate time for the patient and family to express their fears. The fears most often expressed are fear of the unknown, fear of pain, fear of body image change, and fear of dying. During the assessment, the nurse determines how much the patient and family know about the impending surgery and the expected postoperative events. They are encouraged to ask questions and to indicate how much information they wish to re-ceive. Some patients prefer not to have detailed information, whereas others want to know as much as possible. Patients are ap-proached as unique individuals with their own specific learning needs, learning styles, and levels of understanding.
Patients requiring emergency heart surgery may have cardiac catheterization and surgery within several hours of admission. The nurse will have little opportunity to assess and meet their emotional and learning needs before surgery. As a result, patients will need extra help after surgery to adjust to the situation.
The nursing diagnoses for patients awaiting cardiac surgery vary according to each patient’s cardiac disease and symptoms. Most patients have a nursing diagnosis of decreased cardiac output. Preoperative nursing diagnoses for most patients may include:
· Fear related to the surgical procedure, its uncertain outcome, and the threat to well-being
· Deficient knowledge regarding the surgical procedure and the postoperative course
The stress of impending cardiac surgery may precipitate compli-cations that require collaborative management with the physi-cian. Based on the assessment data, potential complications that may develop include:
· Angina or anginal pain equivalent
· Severe anxiety requiring an anxiolytic (anxiety-reducing) medication
· Cardiac arrest
The major goals of the patient may include reducing fear, learn-ing about the surgical procedure and postoperative course, and avoiding complications.
During the preoperative phase of cardiac surgery, the nurse devel-ops a plan of care that includes emotional support and teaching for the patient and family. Establishing rapport, answering questions, listening to fears and concerns, clarifying misconceptions, and pro-viding information about what to expect are interventions the nurse uses to prepare the patient and family emotionally for the surgery and for the postoperative events.
The patient and family are provided time and opportunities to express their fears. If there is fear of the unknown, other surgical experiences that the patient has had can be compared with the impending surgery. It is often helpful to describe to the patient the sensations that are expected. If the patient has already had a cardiac catheterization, the similarities and differences between that procedure and the surgery may be compared. The patient is encouraged to talk about any concerns related to previous experiences.
A discussion of the patient’s fears about pain is initiated. A comparison is made between the pain experienced with cardiac surgery and other pain experiences. The preoperative sedation, the anesthetic, and the postoperative pain medications are described. The nurse reassures the patient that the fear of pain is normal, that some pain will be experienced, that medication to relieve pain will be provided, and that the patient will be closely observed. The pa-tient is encouraged to take pain medication before the pain be-comes severe. Positioning and relaxation will make the pain more tolerable. Patients who have a fear of scarring from surgery are en-couraged to discuss this concern, and misconceptions are cor-rected. It may be helpful to indicate that the health care team members will keep the patient informed about the healing process.
The patient and family are encouraged to talk about their fear of the patient dying. They should be reassured that this fear is nor-mal. For those who only hint about this concern despite efforts to encourage them to talk about their fear, coaching may be helpful (eg, “Are you worrying about not making it through surgery? Most people who have heart surgery at least think about the pos-sibility of dying.”). After the fear is expressed, the patient and family can be helped to explore their feelings.
By alleviating undue anxiety and fear, preparing the patient emotionally for surgery decreases the chance of preoperative problems, promotes smooth anesthesia induction, and enhances the patient’s involvement in care and recovery after surgery. Preparing the family for the events to come helps them to cope, be supportive to the patient, and participate in postoperative and rehabilitative care (Chart 28-9).
Angina may occur because of increased stress and anxiety related to the forthcoming surgery. The patient who develops angina usually responds to normal angina therapy, most commonly nitro-glycerin. Some patients require oxygen and intravenous nitro-glycerin drips (see the Angina Pectoris section).
For patients with extreme anxiety or fear and for whom emo-tional support and education are not successful, medication therapy may be helpful. The anxiolytic agents most commonly used before cardiac surgery are lorazepam (Ativan) and diazepam (Valium).
If cardiac arrest occurs in the preoperative period, advanced cardiac life support is provided.
Patient and family teaching is based on assessed learning needs. Teaching usually includes information about hospitalization, surgery (eg, preoperative and postoperative care, length of surgery, pain and discomfort that can be expected, visiting hours, and pro-cedures in the critical care unit), the recovery phase (eg, length of hospitalization, what to expect from home care and rehabilitation, when normal activities such as housework, shopping, and work can be resumed), and ongoing lifestyle habits. Any changes made in medical therapy and preoperative preparations need to be explained and reinforced.
The patient is informed that physical preparation usually in-volves several showers or scrubs with an antiseptic solution. A sedative may be prescribed the night before and the morning ofsurgery. Most cardiac surgical teams use prophylactic antibiotic therapy, and the antibiotic therapy is initiated before surgery.
If no preadmission teaching has been done and the preopera-tive hospitalization period is very short, teaching the patient and family together may be most effective. Anxiety often increases with the admission process and impending surgery. Teaching the patient and family together capitalizes on their established sup-port relationship. Teaching in this phase should be directed pri-marily by the patient’s and family’s questions. Too much detail may only increase anxiety.
The patient may be offered a tour of the critical care unit, the postanesthesia care unit, or both. (In some hospitals, the patient initially goes to the postanesthesia care unit.) The patient recov-ering from anesthesia may be reassured by having already seen the surroundings and having met someone from the unit. The pa-tient and family are informed about the equipment, tubes, and lines that will be present after surgery and their purposes. They should know to expect monitors, several intravenous lines, chest tubes, and a urinary catheter. Explaining the purpose and the approximate time that these devices will be in place helps to re-assure the patient. Most patients will remain intubated and on mechanical ventilation for 2 to 24 hours after surgery. They need to be aware that this prevents them from talking, and they should be reassured that the staff will be able to assist them with other means of communication.
The nurse takes care to answer the patient’s questions about postoperative care and procedures. Deep breathing and huffing (or coughing), use of the incentive spirometer, and foot exercises are explained and practiced by the patient before surgery. The family’s questions at this time usually focus on the length of the surgery, who will discuss the results of the procedure with them after surgery and when this may occur, where to wait during the surgery, the visiting procedures for the critical care unit, and how they can support the patient before surgery and in the critical care unit.
Expected patient outcomes may include:
1) Demonstrates reduced fear
a) Identifies fears
b) Discusses fears with family
c) Uses past experiences as a focus for comparison
d) Expresses positive attitude about outcome of surgery
e) Expresses confidence in measures to be used to relieve pain
2) Learns about the surgical procedure and postoperative course
a) Identifies the purposes of the preoperative preparation procedure
b) Tours the critical care unit, if desired
c) Identifies limitations expected after surgery
d) Discusses expected immediate postoperative environment (eg, tubes, machines, nursing surveillance)
e) Demonstrates expected activities after surgery (eg, deep breathing, huffing [coughing], foot exercises)
3) Shows no evidence of complications
a) Reports anginal pain is relieved with medications and rest
b) Takes medications as prescribed
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