Home | | Medical Surgical Nursing | Nursing Process: The Patient Who Has Had Cardiac Surgery

Chapter: Medical Surgical Nursing: Management of Patients With Coronary Vascular Disorders

| Study Material, Lecturing Notes, Assignment, Reference, Wiki description explanation, brief detail |

Nursing Process: The Patient Who Has Had Cardiac Surgery

Nursing Process: The Patient Who Has Had Cardiac Surgery
Initial postoperative care focuses on achieving or maintaining hemodynamic stability and recovery from general anesthesia.

NURSING PROCESS: THE PATIENT WHO HAS HAD CARDIAC SURGERY

 

Initial postoperative care focuses on achieving or maintaining hemodynamic stability and recovery from general anesthesia. Care may be provided in the postanesthesia care unit or inten-sive care unit. After hemodynamic stability and recovery from general anesthesia have been achieved, the patient is transferred to a surgical stepdown unit with telemetry. Care focuses on wound care, progressive activity, and nutrition. Education about medications and risk factor modification is emphasized (see Plan of Nursing Care: Care of the Patient After Cardiac Surgery). Dis-charge from the hospital usually occurs 3 to 5 days after CABG or 1 to 3 days after MIDCAB. Patients can expect fewer symptoms from CAD and an improved quality of life. CABG has been shown to increase the life span of high-risk patients—those with left main artery blockages, left ventricular dysfunction with multivessel blockages, three-vessel blockages with one being the left anterior descending artery, and diabetes (Eagle et al., 1999).

 

The immediate postoperative period for the patient who has undergone cardiac surgery presents many challenges to the health care team. All efforts are made to facilitate the transition from the operating room to the critical care unit or PACU with min-imal risk. Specific information about the operation and impor-tant factors about postoperative management are communicated by the surgical team and anesthesia personnel to the critical care nurse, who then assumes responsibility for the patient’s care. Figure 28-10 presents a graphic overview of the many aspects of postoperative care for the cardiac surgical patient.


 

Assessment

 

When the patient is admitted to the critical care unit or PACU and for at least every 12 hours thereafter, a complete assessment of all systems is performed to determine the postoperative status of the patient compared with the preoperative baseline and to identify anticipated changes since surgery. The following param-eters are assessed:

 

Neurologic status: level of responsiveness, pupil size and reactionto light, reflexes, facial symmetry, movement of extremities, and hand grip strength

 

Cardiac status: heart rate and rhythm, heart sounds, arterialblood pressure, central venous pressure (CVP), pulmonary artery pressure, pulmonary artery wedge pressure (PAWP), left atrial pressure, waveforms from the invasive blood pres-sure lines, cardiac output or index, systemic and pulmonary vascular resistance, pulmonary artery oxygen saturation (SvO2) if available, mediastinal chest tube drainage, and pacemaker status and function

 

Respiratory status: chest movement, breath sounds, ventilatorsettings (eg, rate, tidal volume, oxygen concentration, mode such as synchronized intermittent mandatory ventilation, positive end-expiratory pressure, pressure support), respira-tory rate, ventilatory pressure, arterial oxygen saturation (SaO2), percutaneous oxygen saturation (SpO2), end-tidal CO2, pleural chest tube drainage, arterial blood gases

 

Peripheral vascular status: peripheral pulses; color of skin,nailbeds, mucosa, lips, and earlobes; skin temperature; edema; condition of dressings and invasive lines

 

Renal function: urinary output; urine specific gravity and os-molality may be assessed

Fluid and electrolyte status: intake, output from all drainagetubes, all cardiac output parameters, and the following indications of electrolyte imbalance:

 

·      Hypokalemia: digitalis toxicity, dysrhythmias, ECGchanges (U wave, atrioventricular block, flat or inverted T waves)

·       Hyperkalemia: mental confusion, restlessness, nausea,weakness, paresthesias of extremities, dysrhythmias, ECG changes (tall, peaked T waves; increased ampli-tude, widening QRS complex; prolonged QT interval)

·       Hypomagnesemia: paresthesias, carpopedal spasm, musclecramps, tetany, irritability, tremors, hyperexcitability, hyperreflexia, cardiac dysrhythmias, ECG changes (pro-longed PR and QT intervals; broad, flat T waves), dis-orientation, depression, hypotension, seizures

·      Hypermagnesemia: vasodilation, hypotension, hypore-flexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, respiratory depression, coma, apnea, cardiac arrest

·      Hyponatremia: weakness, fatigue, confusion, seizures,coma

·      Hypocalcemia: paresthesias, carpopedal spasm, musclecramps, tetany

·      Hypercalcemia: digitalis toxicity, asystole

 

Pain: nature, type, location, duration (incisional pain must bedifferentiated from anginal pain); apprehension; response to analgesics

 

Some patients who have had a MIDCAB using a midsternal incision or an internal mammary artery CABG experience ulnar nerve paresthesia on the same side of the body as the graft. The paresthesia may be temporary or permanent. Patients who have had CABG using the gastroepiploic artery may experience an ileus for a longer period after surgery and have abdominal pain at the site of the incision and pain at the site of the chest incision.

 

Assessment also includes observing all equipment and tubes to determine whether they are functioning properly: endotracheal tube, ventilator, end-tidal CO2 monitor, SpO2 monitor, pulmonary artery catheter, SvO2 monitor, arterial and intravenous lines, intravenous infusion devices and tubing, cardiac monitor, pacemaker, chest tubes, and urinary drainage system.

 

As the patient regains consciousness and progresses through the postoperative period, the nurse expands the assessment to in-clude parameters indicative of psychological and emotional sta-tus. The patient may exhibit behavior that reflects denial or depression or may experience postcardiotomy psychosis. Charac-teristic signs of psychosis include transient perceptual illusions, vi-sual and auditory hallucinations, disorientation, and paranoid delusions.

The family’s needs also should be assessed. The nurse ascertains how they are coping with the situation; determines their psycho-logical, emotional, and spiritual needs; and finds out whether they are receiving adequate information about the patient’s condition.

 

ASSESSING FOR COMPLICATIONS

 

The patient is continuously assessed for indications of impending complications (Table 28-8). The nurse and the surgeon function collaboratively to identify early signs and symptoms of complica-tions and to institute measures to reverse their progression.





Decreased Cardiac Output

 

A decrease in cardiac output is always a threat to the patient who has had cardiac surgery. It can have a variety of causes:

 

Preload alterations: too little or too much blood volume re-turning to the heart because of hypovolemia, persistent bleeding, cardiac tamponade, or fluid overload

Afterload alteration: hypertension and arterioles that are tooconstricted or too dilated because of alterations in body temperature or use of vasoconstrictors and vasodilators

Heart rate alterations: too fast, too slow, or dysrhythmias

Contractility alterations: cardiac failure, MI, electrolyte imbal-ances, hypoxia

 

Fluid Volume and Electrolyte Imbalance

 

The risk for fluid and electrolyte imbalance may occur after car-diac surgery. Nursing assessment for these complications includes monitoring of intake and output, weight, PAWP, left atrial pres-sure and CVP readings, hematocrit levels, distention of neck veins, edema, liver size, breath sounds (eg, fine crackles, wheezing), and electrolyte levels. Changes in serum electrolytes are reported promptly so that treatment can be instituted. Especially important are dangerously high or dangerously low levels of potassium, mag-nesium, sodium, and calcium.

 

Impaired Gas Exchange

 

Impaired gas exchange is another possible complication after car-diac surgery. All body tissues require an adequate supply of oxy-gen and nutrients for survival. To achieve this after surgery, an endotracheal tube with ventilator assistance may be used for 24 or more hours. The assisted ventilation is continued until the pa-tient’s blood gas measurements are acceptable and the patient demonstrates the ability to breathe independently. Patients who are stable after surgery may be extubated as early as 2 to 4 hours after surgery, which reduces their anxiety regarding their limited ability to communicate.

 

The patient is continuously assessed for signs of impaired gas exchange: restlessness, anxiety, cyanosis of mucous mem-branes and peripheral tissues, tachycardia, and fighting the ven-tilator. Breath sounds are assessed often to detect fluid in the lungs and monitor lung expansion. Arterial blood gas values are monitored. Arterial blood gases, SpO2, SaO2, and end-tidal CO2 are assessed for decreased oxygen and increased carbon dioxide.

 

Impaired Cerebral Circulation

 

Brain function depends on a continuous supply of oxygenated blood. The brain does not have the capacity to store oxygen and must rely on adequate continuous perfusion by the heart. It is im-portant to observe the patient for any symptoms of hypoxia: rest-lessness, headache, confusion, dyspnea, hypotension, and cyanosis. An assessment of the patient’s neurologic status includes level of consciousness, response to verbal commands and painful stimuli, pupil size and reaction to light, facial symmetry, movement of ex-tremities, hand grip strength, presence of pedal and popliteal pulses, and temperature and color of extremities. Any indication of a changing status is documented, and abnormal findings are re-ported to the surgeon because they may signal the beginning of a complication. Hypoperfusion or microemboli may produce cen-tral nervous system injury after cardiac surgery.

 

Diagnosis

 

NURSING DIAGNOSES

 

Based on the assessment data and the type of surgical procedure performed, major nursing diagnoses of the patient may include:

·        Decreased cardiac output related to blood loss, compro-mised myocardial function, and dysrhythmias

·      Impaired gas exchange related to trauma of extensive chest surgery

·       Risk for deficient fluid volume (and electrolyte imbalance) related to alteration in circulating blood volume

·       Disturbed sensory perception (visual or auditory) related to excessive environmental stimuli (critical care environment, surgical experience), insufficient sleep, psychological stress, altered sensory integration, and electrolyte imbalances

·      Acute pain related to surgical trauma and pleural irritation caused by chest tubes

·       Ineffective tissue perfusion (renal, cerebral, cardiopulmonary, gastrointestinal, peripheral) related to decreased cardiac output, hemolysis, vasopressor drug therapy, venous stasis, embolization, underlying atherosclerotic disease, effects of vasopressors, or coagulation problems

·      Ineffective thermoregulation related to infection or post-pericardiotomy syndrome

·      Deficient knowledge about self-care activities

 

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

Based on the assessment data, potential complications that may develop include:

 

·      Cardiac complications: heart failure, MI, stunned myo-cardium, dysrhythmias, tamponade, cardiac arrest

 

·       Pulmonary complications: pulmonary edema, pulmonary emboli, pleural effusions, pneumothorax or hemothorax, respiratory failure, acute respiratory distress syndrome

 

·      Hemorrhage

 

·      Neurologic complications: CVA (brain attack, stroke), air emboli

 

·      Renal failure, acute or chronic

 

·       Electrolyte imbalances

 

·       Hepatic failure

 

·       Coagulopathies

 

·       Infection, sepsis

 

Planning and Goals

 

The major goals for the patient include restoration of cardiac out-put, adequate gas exchange, maintenance of fluid and electrolyte balance, reduction of symptoms of sensory-perception alterations, relief of pain, maintenance of adequate tissue perfusion, mainte-nance of normal body temperature, learning self-care activities, and absence of complications.

 

Nursing Interventions

 

RESTORING CARDIAC OUTPUT

 

Nursing management of the patient involves continuously ob-serving the patient’s cardiac status and notifying the surgeon of any changes that indicate decreased cardiac output. The nurse and the surgeon then work collaboratively to correct the problem.

 

In evaluating the patient’s cardiac status, the nurse primarily determines the effectiveness of cardiac output through clinical observations and routine measurements: serial readings of blood pressure, heart rate, CVP, arterial pressure, and left atrial or pul-monary artery pressure.

 

Renal function is related to cardiac function, as blood pressure and heart rate drive glomerular filtration; therefore, urinary out-put is measured and recorded. Urine output of less than 25 mL/hr may indicate a decrease in cardiac output. Urine specific gravity may also be assessed (normal: 1.010 to 1.025), as may urine osmolality. Inadequate fluid volume may be manifested by low urinary output and high specific gravity, whereas overhydration is manifested by high urine output with low specific gravity.

 

The growth and function of body cells depend on adequate cardiac output to provide a continuous supply of oxygenated blood to meet the changing demands of the organs and body sys-tems. Because the buccal mucosa, nailbeds, lips, and earlobes are sites with rich capillary beds, they should be observed for cyanosis or duskiness as possible signs of reduced heart action. Moist or dry skin may indicate vasodilation or vasoconstriction, respec-tively. Distention of the neck veins or of the dorsal surface of the hand raised to heart level may signal a changing demand or di-minishing capacity of the heart. If cardiac output has fallen, the skin becomes cool, moist, and cyanotic or mottled.

 

Dysrhythmias, which may arise when poor perfusion of the heart exists, also serve as important indicators of cardiac function. The most common dysrhythmias encountered during the post-operative period are atrial fibrillation, bradycardias, tachycardias, and ectopic beats. Continuous observation of the cardiac moni-tor for various dysrhythmias is an essential part of patient care and management.

 

Any indications of decreased cardiac output are reported promptly to the physician. These assessment data and results of diagnostic tests are used by the physician to determine the cause of the problem. After a diagnosis has been made, the physician and the nurse work collaboratively to restore cardiac output and prevent further complications. When indicated, the physician prescribes blood components, fluids, digitalis or other antidys-rhythmics, diuretics, vasodilators, or vasopressors. When additional surgery is necessary, the patient and family are prepared for the procedure.

 

PROMOTING ADEQUATE GAS EXCHANGE

 

To ensure adequate gas exchange, the nurse assesses and main-tains the patency of the endotracheal tube. The patient is suc-tioned when wheezes, coarse crackles, or rhonchi are present. Suctioning may be performed with an in-line suction catheter; the nurse and respiratory therapist determine if the ventilator’s fractional inspired oxygen (FIO2) should be increased for three or more breaths before the patient is suctioned. Alternatively, 100% oxygen is delivered to the patient by a manual resuscitation bag (eg, Ambu-Bag) before and after suctioning to minimize the risk of hypoxia that can result from the suctioning procedure. Arterial blood gas determinations are compared with baseline data, and changes are reported to the physician promptly.

 

Because a patent airway is essential for oxygen and carbon diox-ide exchange, the endotracheal tube must be secured to prevent it from slipping into the right mainstem bronchus and occluding the left bronchus. When the patient’s condition stabilizes, body posi-tion is changed every 1 to 2 hours. Frequent changes of patient po-sition provide for optimal pulmonary ventilation and perfusion by allowing the lungs to expand more fully. The nurse assesses breath sounds to detect crackles, wheezes, and fluid in the lungs.

 

The patient is usually weaned from the ventilator and extu-bated within 24 hours of CABG. Physical assessment and arterial blood gas results guide the process. Before being extubated, the patient should have cough and gag reflexes and stable vital signs; be able to lift the head off the bed or give firm hand grasps; have adequate vital capacity, negative inspiratory force, and minute volume appropriate for body size; and have acceptable arterial blood gas levels while breathing warmed humidified oxygen with-out the assistance of the ventilator.

 

Extubation has been performed within these parameters with-out any adverse effects on the patient’s condition or prognosis.

During this time, the nurse assists with the weaning process and eventually with removal of the endotracheal tube. Deep breath-ing and forced expiration technique (FET, huffing) or coughing are encouraged at least every 1 to 2 hours after extubation to open the alveolar sacs and provide for increased perfusion. FET is the rapid exhalation of a deep breath using the diaphragm and ab-dominal muscles to force air out through an open mouth and glottis (the glottis is not held closed then suddenly opened, as in a cough). Patients may experience less pain with FET than coughing, which may increase the frequency with which a patient performs the exercises. The patient should be taught and assisted to splint the chest incision before and during FET or coughing to minimize discomfort.

 

MAINTAINING FLUID AND ELECTROLYTE BALANCE

 

To promote fluid and electrolyte balance, the nurse carefully assesses intake and output. Flow sheets are used to determine pos-itive or negative fluid balance. All fluid intake is recorded, includ-ing intravenous, nasogastric tube, and oral fluids. All output is recorded, including urine, nasogastric drainage, and chest drainage.

Hemodynamic parameters (ie, blood pressure, pulmonary wedge and left atrial pressures, and CVP) are correlated with in-take, output, and weight to determine the adequacy of hydra-tion and cardiac output. Serum electrolytes are monitored, and the patient is observed for signs of potassium, magnesium, sodium, or calcium imbalance (ie, hypokalemia, hyperkalemia, hypomagnesemia, hyponatremia, or hypocalcemia).

 

Any indications of dehydration, fluid overload, or electrolyte imbalance are reported promptly, and the physician and nurse work collaboratively to restore fluid and electrolyte balance. The patient’s response is monitored.

 

MINIMIZING SENSORY-PERCEPTION IMBALANCE

 

A large number of patients experience abnormal behaviors that occur with varying intensity and duration. In the early years of cardiac surgery, this phenomenon occurred more frequently than it does today. At that time, it was attributed to inadequate cere-bral perfusion during surgery, microemboli, and the length of time that the patient remained on the CPB machine. Advances in surgical techniques have significantly decreased these factors. Today, when it occurs, it is thought to be caused by anxiety, sleep deprivation, increased sensory input, and disorientation to night and day when the patient loses track of time (Arrowsmith et al., 1999; Braunwald et al., 2001; Fuster et al., 2001). An important finding is that patients who do not or cannot express anxiety be-fore surgery and those who are not able to sleep postoperatively are more prone to develop psychosis in the postoperative period. Psychosis may appear after a 2- to 5-day lucid interval.

 

Basic comfort measures used in conjunction with prescribed analgesics potentiate the effects of the analgesics and promote rest. The patient is assisted in changing positions every 1 to 2 hours and is positioned in such a way to avoid strain on incisions and chest tubes. Nursing care is scheduled as much as possible to provide undisturbed periods of rest. As the patient’s condition stabilizes and the patient is disturbed less frequently for monitoring and therapeutic procedures, rest periods can be extended. As much uninterrupted sleep as possible is provided, especially during the patient’s normal hours of sleep.

 

The nurse monitors the patient for signs of denial and provides an opportunity for emotional expression during the preoperative period. Careful explanations of all procedures and of the need for cooperation help to keep the patient oriented throughout the postoperative course. Continuity of care is desirable; a familiar face and a nursing staff with a consistent approach promote the deliv-ery of quality nursing care. A well-designed and individualized plan of nursing care can assist the nursing team in coordinating their efforts for the emotional well-being of the patient.

 

RELIEVING PAIN

 

Deep pain may not be reflected in the immediate area of injury but occur in a broader, more diffuse area. Patients who have had cardiac surgery experience pain caused by the interruption of in-tercostal nerves along the incision route and irritation of the pleura by the chest catheters. Incisional pain may also be experi-enced from peripheral vein or artery graft harvest sites.

 

It is essential to observe and listen to the patient for verbal and nonverbal clues about pain. The nurse accurately records the na-ture, type, location, and duration of the pain. (Chest incisional pain must be differentiated from anginal pain.) The patient is en-couraged to use patient-controlled analgesia or accept medication as often as it is prescribed to reduce the amount of pain. Physical support of the incision during deep breathing and FET (or cough-ing) also helps to minimize pain. The patient should then be able to participate in respiratory exercises and to increase self-care progressively.

 

Pain produces tension, which may stimulate the central ner-vous system to release adrenaline, which results in constriction of the arterioles and increased heart rate. This can cause increased afterload and decreased cardiac output. Opioids alleviate anxiety and pain and induce sleep, which reduces the metabolic rate and oxygen demands. After the administration of opioids, any obser-vations indicating relief of apprehension and pain are docu-mented in the patient’s record. The patient is observed for any respiratory depressant effects of the analgesic. If respiratory de-pression occurs, an opioid antagonist (eg, naloxone [Narcan]) is used to counteract the effect.

 

MAINTAINING ADEQUATE TISSUE PERFUSION

 

Peripheral pulses (eg, pedal, tibial, popliteal, femoral, radial, brachial) are routinely palpated to assess for arterial obstruction. If a pulse is absent in any extremity, the cause may be prior catheterization of that extremity. The newly identified absence of any pulse is immediately reported to the physician.

 

Thrombus formation and resulting embolus formation also can result from injury to the intima of the blood vessels, dislodg-ing a clot from a damaged valve, loosening of mural thrombi, and coagulation problems. Air embolism may occur as a result of CPB or central venous cannulation. Symptoms of embolization vary according to site. The usual embolic sites are the lungs, coronary arteries, mesentery, spleen, extremities, kidneys, and brain. The patient is observed for:

 

·      Chest pain and respiratory distress with pulmonary embo-lus or MI

 

·      Midabdominal or midback pain

 

·      Pain, cessation of pulses, blanching, numbness, or coldness in an extremity

 

·      Decreased urine output

 

·      One-sided weakness and pupillary changes, as occur in CVAs (brain attacks, strokes)

 

All such symptoms are promptly reported to the physician. After surgery, the following measures are taken to prevent venous stasis, which can cause thrombus formation and subsequent embolization:

 

·        Applying elastic compression stockings or elastic bandage wrap and pneumatic antiembolic stockings

 

·      Discouraging crossing of legs

 

·       Avoiding use of the knee gatch on the bed

 

·       Omitting pillows in the popliteal space

 

·       Instituting passive exercises followed by active exercises to promote circulation and prevent loss of muscle tone (pa-tients need to ambulate as early as possible)

 

Inadequate renal perfusion can occur as a complication of car-diac surgery. One possible cause is low cardiac output. Trauma to blood cells during CPB can cause hemolysis of red blood cells, which then occlude the renal glomeruli. Use of vasopressor agents to increase blood pressure may constrict the renal arterioles and reduce blood flow to the kidneys.

Nursing management includes accurate measurement of urine output. An output of less than 25 mL/hr may indicate hypo-volemia. Urine specific gravity can be monitored to determine the kidneys’ ability to concentrate urine in the renal tubules. Rapid-acting diuretics or inotropic medications (eg, digoxin [Lanoxin], isoproterenol [Isuprel]) may be prescribed to increase cardiac out-put and renal blood flow. The nurse should be aware of the pa-tient’s blood urea nitrogen, serum creatinine, and urine and serum electrolyte levels. Abnormal levels are reported promptly because it may be necessary to adjust fluids and the dose or type of med-ication administered. If efforts to maintain renal perfusion are not effective, the patient may require dialysis or continuous renal re-placement therapy.

 

MAINTAINING NORMAL BODY TEMPERATURE

 

Patients are usually hypothermic when admitted to the critical care unit from the cardiac surgical procedure. The patient must be gradually warmed to a normal temperature. This is accom-plished partially by the patient’s own basal metabolic processes and often with the assistance of warmed ventilator air, warm air or warm cotton blankets, or heat lamps. While the patient is hy-pothermic, the clotting process is less efficient, the heart is prone to dysrhythmias, and oxygen does not readily transfer from the hemoglobin to the tissues. Because anesthesia and hypothermia suppress the basal metabolism, oxygen supply usually meets the cellular demand.

 

After cardiac surgery, the patient is at risk for developing ele-vated body temperature caused by infection or postpericardiotomy syndrome. The resultant increase in metabolic rate increases tissue oxygen demands and increases cardiac workload. Measures are taken to prevent this sequence of events or to halt it as soon as it is recognized.

 

Sites of infection include the lungs, urinary tract, incisions, and intravascular catheters. Meticulous care is used to prevent contamination at the sites of catheter and tube insertions. Asep-tic technique is used when changing dressings and when provid-ing endotracheal tube and catheter care. Clearance of pulmonary secretions is accomplished by frequent repositioning of the patient, suctioning, and chest physical therapy, as well as teach-ing and encouraging the patient to breathe deeply and use FET (or cough). Closed systems are used to maintain all intravenous and arterial lines. All invasive equipment is discontinued as soon as possible after surgery.

 

Postpericardiotomy syndrome occurs in approximately 10% to 40% of patients who undergo cardiac surgery. Although the pre-cise cause is unknown, a common factor appears to be trauma, with residual blood in the pericardial sac after surgery. The syn-drome is characterized by fever, pericardial pain, pleural pain, dyspnea, pericardial effusion, pericardial friction rub, and arthral-gia. There may be a combination of these signs and symptoms.

 

Leukocytosis occurs, along with elevation of the erythrocyte sedi-mentation rate. These symptoms frequently appear after the pa-tient is discharged from the hospital.

 

The syndrome must be differentiated from other postoperative complications (eg, infection, incisional pain, MI, pulmonary em-bolus, bacterial endocarditis, pneumonia, atelectasis). Treatment depends on the severity of the symptoms. Bed rest and anti-inflammatory agents, such as salicylates and corticosteroids, produce a dramatic improvement in symptoms.

 

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care

Depending on the type of surgery and postoperative progress, the patient may be discharged from the hospital as early as 1 day after MIDCAB and 3 days after other surgery. Although the patient may be anxious to return home, the patient and family usually have apprehensions about this transition. The family members often express the fear that they are not capable of caring for the patient at home. They often are concerned that complications will occur that they are unprepared to handle.

 

The nurse helps the patient and family to set realistic, achievable goals. A teaching plan that meets the patient’s individual needs is developed with the patient and family. This is done before admission and reviewed each shift through the hospitalization or with each home care and rehabilitation contact. Specific instruc-tions are provided about incision care; signs and symptoms of in-fection; diet; activity progression and exercise; deep breathing, FET (or coughing), incentive spirometry; and smoking cessation; weight and temperature monitoring; the medication regimen; and follow-up visits with home care nurses, the rehabilitation per-sonnel, the surgeon, and the cardiologist or internist.

 

Some patients may have difficulty learning and retaining infor-mation after cardiac surgery. Studies have documented that many patients have difficulties in cognitive function after cardiac surgery that do not occur after other types of major surgery (Arrowsmith et al., 1999; Roach et al., 1996). The patient may experience recent memory loss, short attention span, difficulty with simple math, poor handwriting, and visual disturbances. Patients with these dif-ficulties often become frustrated when they try to resume normal activities and learn how to care for themselves at home. The patient and family are reassured that the difficulty is temporary and will subside, usually in 6 to 8 weeks. In the meantime, instructions are given to the patient at a much slower pace than normal, and a fam-ily member assumes responsibility for making sure that the pre-scribed regimen is followed. All information is provided in writing in the patient’s primary language.

 

Continuing Care

 

Arrangements are made for a home care nurse to provide care when appropriate. Since the length of time that the patient re-mains in the hospital is relatively short, it is particularly impor-tant for the nurse to assess the patient’s and family’s ability to manage care in the home. The education plan is continued by the home care nurse. Vital signs and incisions are monitored, the pa-tient is assessed for signs and symptoms of complications, and support for the patient and family is provided. Additional inter-ventions may include dressing changes, intravenous antibiotic ad-ministration, diet counseling, and tobacco use cessation strategies. Patients and families need to know that cardiac surgery did not cure the patient’s underlying heart disease. Lifestyle changes for risk factor reduction must be made, and medications taken pre-operatively may be prescribed postoperatively.

Patient teaching does not end at the time of discharge from home health. The patient is encouraged to maintain telephone contact with the surgeon, cardiologist, and nurses. This provides the patient and family with reassurance that questions can be an-swered and problems can be resolved if they arise. Many hospi-tals provide family support sessions that help family members cope with their own stress related to the patient’s home health care management. The patient is expected to have a follow-up visit with the surgeon.

 

Many patients and families benefit from supportive programs such as the postcardiac surgery rehabilitation programs offered by many medical centers. These programs provide exercise moni-toring; instructions about diet and stress reduction; information about resuming exercise, work, driving, and sexual activity; assis-tance with tobacco use cessation; and support groups for pa-tients and families. The American Heart Association sponsors the Mended Hearts Club, which provides information as well as an opportunity for families to share experiences.

 

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include the following:

·        Maintains adequate cardiac output

·        Maintains adequate gas exchange

·        Maintains fluid (and electrolyte) balance

·        Experiences decreased symptoms of sensory-perception disturbances

·        Experiences relief of pain

·        Maintains adequate tissue perfusion

·        Maintains normal body temperature

·        Performs self-care activities

 

A typical plan of postoperative nursing care and more-detailed expected outcomes for the cardiac surgery patient are presented in the Plan of Nursing Care.

 

 

Study Material, Lecturing Notes, Assignment, Reference, Wiki description explanation, brief detail


Copyright © 2018-2020 BrainKart.com; All Rights Reserved. Developed by Therithal info, Chennai.