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Cardiac Surgery - Outline

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Generalist Nursing Practice IV: Tertiary Care Across the Lifespan (NURS 4889)

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Temple University

Academic year: 2019/2020

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Cardiac Surgery:

Coronary Surgical Revascularization: - Failed medical management - Presence of left main coronary artery or triple-vessel disease - Not a candidate for PCI (e., lesions are long or difficult to access) - Failed PCI with ongoing chest pain - History of diabetes mellitus - When long-term benefits of CABG are superior to PCI

Coronary Artery Bypass Graft: - Sternotomy with Cardiopulmonary bypass (CPB) - Off-pump coronary artery bypass - sternotomy but no CPB - Robot-assisted surgery - Minimally invasive direct coronary artery bypass (MIDCAB) - alternative to traditional CABG - Uses arteries and veins for grafts - CABG surgery consists of the placement of conduits to transport blood between the aorta, or other major arteries, and the myocardium distal to the blocked coronary artery (or arteries). - CABG surgery requires a sternotomy (opening of the chest cavity) and cardiopulmonary bypass (CPB). - The procedure may involve one or more grafts using the internal mammary artery, saphenous vein, radial artery, gastroepiploic artery, and/or inferior epigastric artery. - Minimally invasive direct coronary artery bypass (MIDCAB) is a technique that offers patients with limited disease an approach to surgical treatment that does not involve a sternotomy and CPB. o The technique requires several small incisions between the ribs. A thoracoscope is used to dissect the IMA. The heart is slowed using a β-adrenergic blocker (e., esmolol [Brevibloc]) or stopped temporarily with adenosine. o A mechanical stabilizer immobilizes the operative site.

Cardiopulmonary Bypass: - During CPB, blood is diverted from the patient’s heart to a machine where it is oxygenated and returned (via a pump) to the patient. This allows the surgeon to operate on a quiet, nonbeating, bloodless heart while perfusion to vital organs is maintained.

Internal Mammary Artery and Saphenous Vein Grafts: - The internal mammary artery (IMA) is the most common artery used for bypass graft. It is left attached to its origin (the subclavian artery) but then dissected from the chest wall. Next, it is anastomosed (connected with sutures) to the coronary artery distal to the blockage. The long-term patency rate for IMA grafts is greater than 90% after 10 years. - Saphenous veins are also used for bypass grafts. The surgeon removes the saphenous vein from one or both legs endoscopically. Sections are attached to the ascending aorta and then to a coronary artery distal to the blockage. The use of antiplatelet therapy and statins after surgery improves vein graft patency. Patency rates of these grafts are 50% to 60% at 10 years.

Nursing Management: Coronary Revascularization: CABG: - ICU for first 24–36 hours - Pulmonary artery catheter: Measure CO, volume status - Intraarterial line - Pleural/mediastinal chest tubes - Continuous ECG - ET tube with ventilation - Epicardial pacing wires - Urinary catheter - NG tube

For patients having CABG surgery, care is provided in the intensive care unit for the first 24 to 36 hours.
Ongoing and intensive monitoring of the patient’s hemodynamic status is critical. The patient will have numerous invasive lines for monitoring cardiac status and other vital organs. These include:
A pulmonary artery catheter for measuring CO and other hemodynamic parameters
An intraarterial line for continuous BP monitoring
Pleural and mediastinal chest tubes for chest drainage
Continuous ECG monitoring to detect dysrhythmias
An endotracheal tube connected to mechanical ventilation
Epicardial pacing wires for emergency pacing of the heart
A urinary catheter to monitor urine output
A nasogastric tube for gastric decompression
Most patients will be extubated within 6 hours and transferred to a step-down unit within 24 hours for continued monitoring of cardiac status.

Complications Related to CPB: - Bleeding and anemia from damage to RBCs and platelets - Fluid and electrolyte imbalances (K+ and Mg) - Hypothermia as blood is cooled as it passes through the bypass machine - Infections

CABG: Postoperative Nursing Care: - Assess patient for bleeding o Chest tube  Monitor with VS q15min, q30, etc o Incision: Clean, dry, intact  Around sternotomy and chest tube sites - Monitor hemodynamic status - Assess fluid status - Replace electrolytes PRN o CBC, coag tests (PTT) o Reverse heparin (Protamine) - Restore temperature o Bear hugger - Monitor for atrial fibrillation (which is common) o PACs? Start meds (beta blockers or amio to prevent afib) - Glycemic control - Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days after CABG surgery. Postoperative atrial fibrillation (AF) occurs in 20% to 50% of patients. o Beta blockers should be restarted as soon as possible after surgery (unless contraindicated) to reduce the incidence of AF. - CBC, coag tests (PTT) - Reverse heparin (Protamine)

Cardiac Tamponade: - Fluid builds up between heat within pericardium - Signs, Symptoms, Diagnosis: o Beck’s Triad - increased JVD, hypotension, diminished heart sounds o Decreased cardiac output o Pulmonary pressures equalize o Pulsus paradoxus o Sudden decrease in chest tube drainage o Chest x-ray – wide mediastinum

Care of the radial artery harvest site includes monitoring sensory and motor function of the distal hand. The patient with radial artery harvest should be on a calcium channel blocker for approximately 3 months to decrease the incidence of arterial spasm at the arm or anastomosis site.
The care of the leg incision is minimal since the use of endoscopic vein harvesting.
The management of the chest wound, which involves a sternotomy, is similar to that of other chest surgeries. Chest incisions are usually closed with Dermabond and do not require dressings.
Other interventions include strategies to manage pain and prevent venous thromboembolism (e., early ambulation, sequential compression device) and respiratory complications (e., use of incentive spirometer, splinting during coughing and deep-breathing exercises).
Postoperatively, patients may experience some cognitive dysfunction. This includes impairment of memory, concentration, language comprehension, and social integration. Patients may inexplicably cry or become teary. Postoperative cognitive dysfunction (POCD) can manifest days to weeks after surgery and may remain a permanent disorder. It is seen in 40% of patients several months after cardiac surgery.

Nursing Management: Discharge Planning and Home Care: - Cardiac rehabilitation - Patient and caregiver teaching o Wound Care  Red, swollen, tender, drainage  Check temp  Clean with soap and water, no creams/lotions o Sternal Precautions  Avoid lifting heavy objects (heavier than jug of milk)  First 3 months  Don’t vacuum  How to get out of chair or bed (don’t use arms to push up) - Physical activity - Resumption of sexual activity - Teach when discuss other physical activity - Typically 7–10 days post MI or when patient can climb two flights of stairs

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Cardiac Surgery - Outline

Course: Generalist Nursing Practice IV: Tertiary Care Across the Lifespan (NURS 4889)

30 Documents

Students shared 30 documents in this course

University: Temple University

Was this document helpful?

Cardiac Surgery:

Coronary Surgical Revascularization:

- Failed medical management

- Presence of left main coronary artery or triple-vessel disease

- Not a candidate for PCI (e.g., lesions are long or difficult to access)

- Failed PCI with ongoing chest pain

- History of diabetes mellitus

- When long-term benefits of CABG are superior to PCI

Coronary Artery Bypass Graft:

- Sternotomy with Cardiopulmonary bypass (CPB)

- Off-pump coronary artery bypass - sternotomy but no CPB

- Robot-assisted surgery

- Minimally invasive direct coronary artery bypass (MIDCAB) - alternative to traditional CABG

- Uses arteries and veins for grafts

- CABG surgery consists of the placement of conduits to transport blood between the aorta, or other major

arteries, and the myocardium distal to the blocked coronary artery (or arteries).

- CABG surgery requires a sternotomy (opening of the chest cavity) and cardiopulmonary bypass (CPB).

- The procedure may involve one or more grafts using the internal mammary artery, saphenous vein, radial

artery, gastroepiploic artery, and/or inferior epigastric artery.

- Minimally invasive direct coronary artery bypass (MIDCAB) is a technique that offers patients with limited

disease an approach to surgical treatment that does not involve a sternotomy and CPB.

oThe technique requires several small incisions between the ribs. A thoracoscope is used to dissect

the IMA. The heart is slowed using a β-adrenergic blocker (e.g., esmolol [Brevibloc]) or stopped

temporarily with adenosine.

oA mechanical stabilizer immobilizes the operative site.

Cardiopulmonary Bypass:

- During CPB, blood is diverted from the patient’s heart to a machine where it is oxygenated and returned

(via a pump) to the patient. This allows the surgeon to operate on a quiet, nonbeating, bloodless heart

while perfusion to vital organs is maintained.

Internal Mammary Artery and Saphenous Vein Grafts:

- The internal mammary artery (IMA) is the most common artery used for bypass graft. It is left attached to

its origin (the subclavian artery) but then dissected from the chest wall. Next, it is anastomosed

(connected with sutures) to the coronary artery distal to the blockage. The long-term patency rate for IMA

grafts is greater than 90% after 10 years.

- Saphenous veins are also used for bypass grafts. The surgeon removes the saphenous vein from one or

both legs endoscopically. Sections are attached to the ascending aorta and then to a coronary artery distal

to the blockage. The use of antiplatelet therapy and statins after surgery improves vein graft patency.

Patency rates of these grafts are 50% to 60% at 10 years.

Nursing Management: Coronary Revascularization: CABG:

- ICU for first 24–36 hours

- Pulmonary artery catheter: Measure CO, volume status

- Intraarterial line

- Pleural/mediastinal chest tubes

- Continuous ECG

- ET tube with ventilation

- Epicardial pacing wires

- Urinary catheter

- NG tube

Cardiac Surgery - Outline

Generalist Nursing Practice IV: Tertiary Care Across the Lifespan (NURS 4889)

Temple University

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Cardiac Surgery - Outline

Course: Generalist Nursing Practice IV: Tertiary Care Across the Lifespan (NURS 4889)

University: Temple University

Students also viewed

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