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Cardiovascular Surgery – Caring for the Patient
Preoperative and Postoperative Care
Through the use of modern techniques, it is possible for surgeons not only to repair damage or deformity of the large blood vessels but also to stop the heart, open it, and perform necessary surgery there.
For purposes of discussion of nursing care, cardiovascular surgical patients may be considered under three general conditions:
Those whose hearts have been opened or entered, as in surgery of the heart valves.
Those in whom surgery is confined to the great vessels or to the exterior of the heart, as in coarctation of the aorta, patent ductus arteriosus, aneurisms, anastamoses, and non perforating wounds of the myocardium.
Those in whom surgery involves the major coronary arteries.
Most patients scheduled for cardiovascular surgery enter the hospital several days prior to surgery. This allows for adequate time to prepare the patient for what lies ahead and adequate time for the staff to develop a rapport with the patient. Establishing a trusting relationship with the patient will provide him with emotional support.
A thorough assessment of the patient must be made. Many members of the health care team will be involved in this phase of preparation.
Stages of Assessment
Stages of Assessment
The assessments carried out in preoperative care include the following:
The physician must complete a thorough physical examination and patient history. He orders the lab work, X-rays, ECGs, and other studies that must be done to obtain baseline data on the patient's immediate preopcondition.
A nursing assessment of the patient must be done. This involves assessing the physical, psychological, social, and spiritual needs of the patient.
The dietician may visit the patient to do a nutritional evaluation and teach the patient about his new postoperative diet.
The physical therapist may visit the patient to instruct him in the postoperative procedures for his rehabilitation. Explanations will be given regarding the importance of advancing activity under the supervision of the staff, and exercise routines will be taught.
An assessment must be made of the patient's coping mechanisms. This may be done by the chaplain, the psychologist, or most commonly, by the nursing personnel. Poor coping mechanisms mean increased anxiety for the patient, and increased anxiety leads to a slower recovery. Early identification of this problem will allow the nursing staff to make provisions for it in the nursing plan of care.
Preoperative Care – Nursing Considerations
The nursing considerations in preoperative management include the following areas:
The nursing staff executes the physician's orders, gathers data, and keeps the physician up to date regarding the patient's status.
Patient education is implemented. The patient is instructed about his postoperative routine and the importance of his participation and cooperation during the postoperative course.
The patient must be fully oriented to the postoperative environment. This includes familiarization with the monitors, machines, and equipment that will be used during the postoperative period. If possible, give the patient a tour of the CCU and allow him to meet some of the nursing personnel.
Reduce patient anxiety by establishing a friendly informative, caring relationship with the patient.
Postoperative care for patients who have had surgery of the heart or great vessels is generally much the same as that given to other chest surgery patients. A possible exception to this generalization is care for the patient who has had surgery of the coronary arteries.
The first 48 hours following cardiovascular surgery are the most critical, and a high degree of alertness and skill in nursing care are essential if death is to be prevented. Intensified nursing care should continue for at least the first five postoperative days.
Pulse, blood pressure, and respiration must be taken and recorded every 15 minutes until they stabilize, usually after 4-8 hours.
Temperatures outside the 97 to 102F range should be reported. Higher temperatures may be an indication of shock or cardiac decompensation.
Postoperative Care - Oxygen Therapy and Psychological Considerations
Oxygen is given by facemask, usually at the rate of 8 liters per minute. After the patient has fully reacted, a nasal cannula is substituted and oxygen is continued at 4 to 6 liters per minute until the physician orders discontinuance. Peripheral signs of cyanosis and ischemia must still be watched for, however. Mottling or blanching of the skin in an extremity--particularly if it is accompanied by other phenomena such as pain, numbness, tingling, or loss of motion--may indicate the presence of an embolus and should be immediately reported.
Any signs of disorientation, such as failure to recognize a member of the family or familiar surroundings, should be reported. A transient state of depression may be expected in the CV surgical patient. In an occasional patient, the depression will degenerate into suicidal tendencies. Postoperative depression may be prevented or its intensity lessened through preoperative explanation of the upcoming procedure and sympathetic consideration of the patient's fears and concerns.
Postoperative Care – Positioning and Turning
Usually, the patient is kept in the dorsal recumbent position until his systolic pressure is more than 100. On specific orders from the physician, a CV surgical patient, other than one who has had coronary artery surgery, may be raised to a semi-Fowler position and may be turned from side to side every two hours.
A blood pressure reading must be taken immediately before and 5 minutes after the patient is raised. If the blood pressure drops after the patient is raised, the head of the bed and the patient must be returned to horizontal for at least 30 minutes before the procedure is repeated.
After stabilization, CV surgical patients should be encouraged to raise deeply lodged secretions by coughing with support in the same manner as other surgical patients.
Such coughing is usually effective, but if it is not, endotracheal suctioning must be employed. Sometimes a mucolytic agent applied in aerosol form may be helpful.
Ribs that were retracted during surgery are the major sources of postoperative pain in the CV surgical patient. During the first 24 to 48 hours, Demerol is given on a schedule and in a quantity sufficient to keep him reasonably comfortable but not enough to depress his mental outlook and cough reflex.
After this initial period, other causes for continued restlessness--such as oxygen deprivation, fear, and positional discomfort--should be looked for and corrected.
Postoperative Care – Underwater Seal Drainage
Underwater Seal Drainage: Nursing care with regard to CV patients with underwater seal drainage is generally the same as that for other chest patients with such drainage equipment in place. Drainage of about 400 to 500 ml of bloody fluid is to be expected from heart surgery patients during the first 24 hours. Absence of drainage fluid in the water seal setup indicates that fluid may be accumulating in the thorax. Thus, drainage volume must be carefully observed and recorded.
Temporary gastric distention is a common occurrence in CV surgical patients. The stomach is intubated and suction applied to reduce distention and relieve any pressure exerted on the heart by the distended stomach.
Postoperative Care – Diet
With permission of the physician, fluids may be given as soon as the patient can tolerate them. The first fluids given should be lukewarm and should not be fruit juices, as they may cause nausea.
Cardiovascular surgical patients are normally markedly thirsty, and they will drink large quantities of fluids. If fluid is retained, intake may have to be restricted. Nursing personnel must diligently monitor and record fluid intake and output.
Also, it may be necessary to weigh the patient daily. The physician probably will permit returning the patient to a soft or normal diet as soon as the patient desires solid food. Solid food should be withheld from the coronary artery surgery patient until abdominal cramps and gas no longer persist.
Postoperative Care – Exercise
The patient, upon regaining consciousness, is encouraged to breathe deeply through the nose deliberately and quietly to ventilate and expand the lungs. Care must be taken not to tire the patient. Other voluntary body movement and exercise are encouraged after the first 24 hours.
The patient is encouraged to comb his hair, reach for objects within normal reach, and then use a pull to raise himself. A pull may be made from wide gauze attached to the foot of the bed and extending to within the patient's reach. A T-handle may be inserted or a knot tied in the end of the pull to facilitate easier grasping. From about the 5th to the 8th day, as determined by the physician, the patient is allowed to dangle his feet for gradually increasing lengths of time, then gradually allowed out of bed more and more until the patient is fully mobile, usually by the 12th to 14th day.
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