Assessing the Patient

Patients are frequently admitted to the hospital the day of the procedure. Therefore, most of the
preoperative evaluation is completed in the physician’s office and during preadmission testing. Nursing
and medical personnel perform a history and physical examination. Preoperative testing consists of a
chest x-ray, ECG, laboratory tests, including coagulation studies, and blood typing and cross-matching.
The health assessment focuses on obtaining baseline physiological, psychological, and social
information. The patient’s and family’s learning needs are identified and addressed. Of particular
importance are the patient’s usual functional level, coping mechanisms, and available support systems.
These affect the patient’s postoperative course, discharge plans, and rehabilitation.
The preoperative history and health assessment should be thorough and well documented because they
provide a basis for postoperative comparison. It is necessary to perform a systematic assessment of all
systems, with emphasis on cardiovascular functioning. The nurse assesses the patient for disorders that
could complicate or affect the postoperative course, such as diabetes, hypertension, and preexisting
disabilities.
The status of the cardiovascular system is determined by reviewing the patient’s symptoms, including
past and present experiences with chest pain, palpitations, and breathing difficulty (dyspnea), leg pain
that occurs with walking (intermittent claudication), and peripheral edema. The patient’s history of major
illnesses, previous surgeries, medication, use of illicit and over-the-counter drugs, herbal supplements,
alcohol, and tobacco is also obtained. Particular attention is paid to blood glucose control in patients with
diabetes because there is a higher incidence of postoperative complications when glycemic control is
poor (Presutti & Millo, 2006).
A complete physical examination is performed, with a focused cardiovascular emphasis, as previously
discussed in detail in Chapter 26. The psychosocial assessment and the assessment of the patient’s and
family’s learning needs are as important as the physical examination. Anticipation of cardiac surgery is a
source of great stress to the patient and family, and patients with high anxiety levels have poorer

outcomes (Gallagher & McKinley, 2007). However, some anxiety is expected, and the work of
worrying
can help patients identify priorities and find coping strategies that help them face the threat of surgery
(Chart 28-12). Questions may be asked to obtain the following information:
• Knowledge and understanding of the surgical procedure, postoperative course, and recovery
• Meaning of the surgery to the patient and family
• Fears regarding the present and future
• Coping mechanisms that are being used
• Support systems in effect
Reducing Fear and Anxiety
The nurse gives the patient and family time and opportunity to express their fears. Topics of concern may
be pain, changes in body image, fear of the unknown, and disability or death. It is often helpful to describe
to the patient the sensations that he or she can expect. It is necessary to describe the preoperative
sedation, the anesthetic, and the postoperative pain medications. The nurse reassures the patient that
the fear of pain is normal, that some pain will be experienced, that medication to relieve pain will be
provided, and that the patient will be closely monitored. In addition, the nurse suggests that the patient
request analgesic medication before the pain becomes severe. If the patient has concerns about scarring
from surgery, the nurse encourages him or her to discuss this issue and corrects any misconceptions.
The patient and family may want to discuss their fear of the patient dying. After the fear is expressed, the
nurse can assure the patient and family that this fear is normal and further explore their feelings. For
patients with extreme anxiety or fear and for whom emotional support and education are not successful,
medication therapy may be helpful. The anxiolytic agents most commonly used before cardiac surgery
are lorazepam (Ativan) and diazepam (Valium).
Monitoring and Managing Potential Complications
Angina may occur because of increased stress and anxiety related to the forthcoming surgery. The
patient who develops angina usually responds to typical angina therapy, most commonly nitroglycerin.
Some patients require oxygen and IV nitroglycerin infusions. Physiologically unstable patients may
require management in a critical care unit preoperatively.
Providing Patient Teaching
Prior to surgery, patients and their families are given specific preoperative instructions. This includes
information about the prescribed medications, including anticoagulants, antihypertensives, and
medications that control diabetes. The patient is instructed to shower with an antiseptic solution.
Teaching also includes information about the hospitalization and surgery. The nurse informs the patient
and family about the equipment, tubes, and lines that will be present after surgery and their purposes.
They should expect monitors, several IV lines, chest tubes, and a urinary catheter. Explaining the
purpose and the approximate time that these devices will be in place helps reassure the patient. Most
patients remain intubated and on mechanical ventilation for 2 to 24 hours after surgery. It is important that
patients realize that this will prevent them from talking, and the nurse should reassure them that the staff
will be able to assist them with other means of communication. The nurse takes care to answer the
patient’s questions about postoperative care and procedures. After the nurse explains deep breathing and
coughing, use of the incentive spirometer, and foot exercises, the patient practices these procedures
before surgery. It is important to discuss the benefit of early and frequent ambulation. The family’s
questions at this time usually focus on the length of the surgery, who will discuss the results of the
procedure with them after surgery, where to wait during the surgery, the visiting procedures for the critical
care unit, and how they can support the patient before surgery and in the critical care unit.
Intraoperative Management
The perioperative nurse performs assessments and prepares the patient as described previously in
Chapters 18 and 19. In addition to assisting with the surgical procedure, perioperative nurses are
responsible for the comfort and safety of the patient. Before the chest incision is closed, chest tubes are
inserted to evacuate air and drainage from the mediastinum and the thorax. Temporary epicardial
pacemaker electrodes may be implanted on the surface of the right atrium and the right ventricle. These
epicardial electrodes can be connected to an external pacemaker if the patient has persistent bradycardia
perioperatively. Possible intraoperative complications include low cardiac output, dysrhythmias,
hemorrhage, MI, stroke, embolization, and organ failure from shock, embolus, or adverse drug reactions.
Astute intraoperative nursing assessment is critical to prevent, detect, and initiate prompt intervention for
these complications.