CORONARY ARTERY BLOCKAGE

CORONARY ARTERY BYPASS GRAFTING

CURRENT AND POTENTIAL PROBLEM ± Post Operative
Patient might experience these complications;  Excessive bleeding after surgery.  Myocardial infarction or heart attack.  Respiratory insufficiency / pneumonia.  Kidney failure.  Heart arrhythmias, or irregular heartbeats.  Infection of the breastbone or the sternum.  Infection can affect incisions of the leg or the hands  Stroke.  Mood swings.  Persisting pain in breastbone.

NURSING MANAGEMENT 
Preoperative Nursing Management.  Intraoperative Nursing Management.  Postoperative Nursing Management.

PREOPERATIVE NURSING MANAGEMENT 
The preoperative nursing management usually begins before hospitalization. Patients with nonacute heart disease may be admitted to hospital the day before or the day of their surgery.

PREOPERATIVE ASSESSMENT 
History  Physical examination  Radiographic examination  Electrocardiogram

PREOPERATIVE ASSESSMENT 
Laboratory analysis  Typing and cross-matching of blood.  Assessing patient¶s functional level  Psychosocial assessment.  Family support system

PHYSICAL EXAMINATION 
General appearance and behavior  Vital signs  Nutritional and fluid status, weight and Height  Inspection and palpation of heart

PHYSICAL EXAMINATION 
Auscultation of heart  JVP  Peripheral pulses.  Peripheral edema.

PSYCHOSOCIAL ASSESSMENT 
Meaning of surgery to patient  Coping mechanisms being used.  Anticipated changes in lifestyle  Support system in effect  Fear regarding present & future  Knowledge & understanding of surgical procedure.

NURSING DIAGNOSIS 
Fear related to surgical procedure, its uncertain outcome, and the threat of well-being.
Goal: To reduce fear.

INTERVENTIONS 
Allowing patient and family to express their fears.  Explain the patient regarding surgery and sensations that are expected during and after the surgery.  Reassuring the patient that fear of pain is normal and explain that some pain will be experienced but certain measures will help to relieve the pain.

COMMUNICATION

INTERVENTIONS 
Encourage the patient to talk about the fear of dying.  Patient should be reassured and misconceptions should be corrected.

NURSING DIAGNOSIS 
Knowledge deficit regarding the surgical procedure and the postoperative course.
Goal: To provide the knowledge regarding surgery

INTERVENTIONS
Patient and family teaching about  Hospitalization  Surgery  Length of surgery  Expected pain and discomfort  Critical care phase  Recovery phase

PATIENT TEACHING

INTERVENTIONS 
Physical preparation before surgery  Medications before surgery  Information regarding equipments, tubes that will be present postoperatively  Teaching the postoperative exercises.  Outcome of the surgery

NURSING DIAGNOSIS 
Potential for complications related to the stress of impending surgery (Angina, Severe anxiety, Cardiac arrest)
Goal: To monitor and manage the complications

INTERVENTIONS 
Assess for complications  Angina: oxygen therapy and nitroglycerine therapy.  Severe anxiety: emotional support  Cardiac arrest: cardiac life support

INTRAOPERATIVE NURSING MANAGEMENT 
Assisting in surgical procedure  Continuous monitoring  Monitoring for complications: dysrhythmias, hemorrhage, MI, CVA, embolization etc.

INTRAOPERATIVE MANAGEMENT

POST OPERATIVE NURSING MANAGEMENT
ASSESSMENT:  Neurological status  Cardiac status  Respiratory status  Peripheral vascular status  Renal function  Fluid & electrolyte status

POST OPERATIVE ASSESSMENT Contd« 
Pain  Assessment of equipments and tubings  Psychological and emotional status as patient regains consciousness  Assessing for complications.

ASSESSMENT

NURSING DIAGNOSIS 
Decreased cardiac output related to blood loss and compromised myocardial function
Goal: To restore cardiac output

INTERVENTIONS 
Monitor cardiovascular status  Assess arterial pressure every 15 min. until stable  Ascultate for heart sounds and rhythms  Assess all peripheral pulses  Hemodynamic monitoring  ECG monitoring

INTERVENTIONS 
Assess cardiac enzymes  Monitor urinary output  Observe for persistent bleeding  Observe for cardiac temponade  Observe for cardiac failure  Observe for myocardial infarction.

NURSING DIAGNOSIS 
Risk for impaired gas exchange related to trauma of extensive chest surgery
Goal: To maintain adequate gas exchange

INTERVENTIONS 
Maintain proper ventilation  Monitor arterial blood gases, tidal volumes, peek inspiratory pressures and extubation parameters  Auscultate chest for breath sounds  Provide chest physiotherapy as prescribed

INTERVENTIONS 
Promote deep breathing coughing and turning, use of incentive spirometer.  Teach incisional splinting with a cough pillow to decrease discomfort during deep breathing and coughing  Suction tracheobronchial secretions as needed, using aseptic technique

EARLY AMBULATION

NURSING DIAGNOSIS 
Risk for alteration in fluid volume and electrolyte balance related to alteration in blood volume
Goal: To maintain fluid and electrolyte balance

INTERVENTIONS 
Maintain intake and output chart  Assess the following parameters: LAP, BP, CVP, PAWP, weight, electrolyte levels, hematocrit, JVP, tissue turgor, breath sounds, urinary output etc.  Measure post operative chest drainage  Be alert to serum electrolyte levels

NURSING DIAGNOSIS 
Pain related to operative trauma and pleural irritation caused by chest tubes
Goal: To relieve pain

INTERVENTION 
Record nature, type, location and duration  Providing comfortable position  Assist patient to differentiate between surgical and anginal pain  Administer prescribed pain medication  Encourage relaxation techniques

PAIN MEDICATION

NURSING DIAGNOSIS 
Risk for alteration in renal perfusion related to decreased cardiac output, hemolysis, or vasopressor therapy
Goal: To maintain adequate renal perfusion

INTERVENTION 
Measure urine output strictly  Monitor renal function tests  Report to physician if urine output less  Administer medications as prescribed

NURSING DIAGNOSIS 
Risk for hypothermia/hyperthermia related to cardiopulmonary bypass surgery, infections etc.
Goal: To maintain normal body temperature

INTERVENTIONS 
Warm the patient gradually with warm air or warm blankets or heat lamps  Assess for dysrythmias due to hypothermia  Assess for elevated body temperature  Assess for infection ( lungs, urinary tract, incisions and intravascular catheter

INTERVENTIONS 
Use the aseptic technique while dressing and other procedure  Using proper hand washing technique  Meticulous care to be taken to prevent contamination at the sites of catheter and tube insertion  Care of the graft donor site.

CARE OF THE GRAFT DONOR SITE

RADIAL ARTERY

CARE OF CHEST TUBE

NURSING DIAGNOSIS 
Risk for sensory- perceptual alterations related to sensory overload
Goal: to prevent postcardiotomy syndrome

INTERVENTIONS 
Explain all procedures to patient  Plan nursing care to provide for periods of uninterrupted sleep with day-night pattern  Decrease sleep preventing environmental stimuli as much as possible

INTERVENTIONS 
Promote continuity of care from nurse to nurse  Orient the patient to time, place and person. Encourage the family to visit at regular times  Teach relaxation and diversional techniques  Observe for signs of pericardiotomy syndrome

NURSING DIAGNOSIS 
Knowledge deficit about self care activities
Goal: to help the patient in the performance of self care activities

INTERVENTIONS
Develop teaching plan for patient and family specifically about:  Diet  Activity progression  Exercise  Deep breathing, coughing exercises  Medication regimen  Follow up

PATIENT HEALTH EDUCATION
For post operative care; I. Wound care  Do not wet the wound (first 3 weeks after surgery).  Keep forearm / leg wounds dry.  If wound get wet, immediately dap with dry towel.  Use antiseptic soap when bath (after 3 weeks

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