Coronary Artery Bypass Graft (CABG) Patient teaching/preparation

• Invasive surgery that restores vascularization of the heart
muscle.
• It bypasses an obstruction of the coronary arteries.
• Most effective in pts. with sufficient ventricular function (EJF
>50%).
Indications:
• >50% blockage of left main coronary
artery with anginal events
• Significant two-vessel disease with
unstable angina
• Triple-vessel disease with or without
angina.
• HF or cardiogenic shock with acute MI or
ischemia.
• Persistent ischemia
• Inaccessible coronary arteries
• Heart valve problems
• CAD unresponsive to medical Tx
Complications:
• ↓ CO – from:
• Cardiac tamponade – bleeding from test tube occlusion.
Causes build up in pericardium.
• Hypovolemia – from bleeding, ↓ intravascular volume or
vasodilation; results in ↓ BP and ↓ urine output.
• LV HF – might occur with hypervolemia or MI.
• Hypothermia – causes vasoconstriction, metabolic acidosis and
HTN.
• Pulmonary complications – atelectasis, pneumonia or pulmonary
edema.
• Electrolyte imbalance – K and Mg depletion
• Neurologic deficit – hypotension, blood clot can cause
intraoperative cerebrovascular accident.
• Assess patients physical and psychosocial readiness.
• Instruct/inform client to:
 Splint incision when coughing and deep breathing.
Pre-procedure  Do arm and leg exercise
 Report pain.
• Can be elective or emergency procedure
• Check consent form for signature. • Inform pt. to expect the ffg after surgery:
• Confirm x-ray, ECG and lab test  ED tube and mechanical ventilator is used for airway management for
• Complete baseline assessment: pt. cognition, health issues, and support system. several hrs.
• Administer pre-op meds: anxiolytics (lorazepam, diazepam), prophylactic  Inability to talk while in ED tube
 Possible sternal or leg incision
antibiotics, and anticholinergics (scopolamine)
• Monitor HR and rhythm, oxygenation, other VS.  Early ambulation
 Admin of pain meds
 One or two chest tubes
 Indwelling urinary catheter and pacer wires
 Hemodynamic monitoring devices
• Inform pt. to discontinue or alter or meds as prescribed by MD.
Meds frequently discontinued:
Intra-procedure
 Diuretic: 2-3 days before CABG
• Extracardiac vein (saphenous), artery (radial or mammary), or synthetic graft is  Aspirin and other anticoagulants: 1 week before.
used to bypass obstruction. Meds frequently continued:
• Usually, a median sternotomy incision is made for heart and great vessel
visualization.  K+ supplements
• Pt. is then placed on cardiopulmonary bypass; Pt. temperature might be  Antidysrhythmic
lowered.  Antihypertensive
• To stop the heart a cardioplegic solution is used  Insulin
• Artery or vein is harvested then anastomosed from aorta to affected coronary • Instruct pt. to:
artery.  Monitor infection
• Hypothermic pt. is then rewarmed by heat exchanges on bypass machine.  Treat angina: maintain supply of nitro
• Graft is monitored for leakage and patency.  Adhere to medication regimen.
• A pacemaker wire (sutured in myocardium) might be placed, and chest tube is  Monitor BG levels
inserted.  Stop smoking, eat heart-healthy diet
• Finally, pt. is transported to ICU.  Physical activity
• Nurse would: place padding on pts. bony prominences, inform pts. family of  Remain at home for the first week and gradually resume activity.
surgical progress, assist in monitoring UO and blood loss, document surgical
events, assist in ICU placement.
Post-procedure
• Maintain adequate ventilation and airway patency: check RR, breath sounds, SaO2, ventilator settings; suction if needed; assist
extubation.
• Encourage pt. to splint incision, deep breath and coughing.
• Turn pt. from side to side as tolerated within 2 hr. after extubation. Transfer pt. to chair within 24hr. Ambulate (25-100 ft) TID by first
operative day.
• Consult respiratory services and case management services.
• Monitor HR and rhythm.
• Maintain adequate blood volume: monitor and control BP and CO; monitor hemodynamic pressure and catheter placement; monitor
LOC q 30-60 min until client awakens from anesthesia, then q 2-4 hr.
• Monitor chest tube drainage and patency; measure drainage at least once an hour; report volume >150 ml/hr (sign of hemorrhage)
• Assess and control pain, admin analgesics as per order.
• Monitor fluid and electrolytes
• Monitor and prevent infection: use aseptic technique, admin antibiotic, monitor WBC, redness, drainage, fever, temperature.
Create a concept map for the patient undergoing PCI or a CABG

Real word example:

I had a 72 yr. old male patient who has 2 days post op after CABG surgery. The patient had a history of CVA, cardiomyopathy and CAD. He had an angiography performed and was found
to have a coronary occlusion and was scheduled to have CABG surgery after a couple of days. During my shift the patient’s vital signs where stable and there was no signs of infection or
complications. The patient was encouraged to deep breath, use his IS and ambulate as tolerated. Patient was alert and oriented and denies any pain. He was also very excited to go home and see
his wife.