Critical Care Nursing - Clinical

Seminar Title :
CABG ( Coronary Artery Bypass Graft ) OR ACB ( AortoCoronary Bypass ) Served To : Dr. Lourance Al Hadid MsN. Hadeel Taleb Prepared by : Khaled Mahajna

Outlines
Definition of CABG Review of Coronary Arteries Purposes Indications for CABG Contraindications for CABG Procedure Nursing Management
Pre operative Phase Intra operative Phase Post operative phase

Complications References

Objectives
At the end of this presentation the students will be able to : 1. 2. 3. 4. 5. Define CABG Describe the review of coronary arteries Describe the process of the procedure Use the nursing management Define the indications , contraindications , complications

Definition
Is a surgical procedure performed to relieve angina and reduce the risk of death from coronary artery disease. Arteries or veins from elsewhere in the patient's body are grafted (internal thoracic arteries, radial arteries and saphenous) to the coronary arteries to bypass atherosclerotic narrowings and improve the blood supply to the coronary circulation supplying the myocardium (heart muscle). This surgery is usually performed with the heart stopped .

Number Of Bypass
The terms single bypass, double bypass, triple bypass, quadruple bypass and quintuple bypass refer to the number of coronary arteries bypassed in the procedure. In other words : double bypass means two coronary arteries are bypassed (e.g. the left anterior descending (LAD) coronary artery and right coronary artery (RCA) triple bypass means three arteries are bypassed (e.g. LAD, RCA, left circumflex artery (LCX) quadruple bypass means four vessels are bypassed (e.g. LAD, RCA, LCX, first diagonal artery of the LAD) Bypass of more than four coronary arteries is uncommon.

Review Of Coronary Arteries

Purposes
Restore blood flow to the heart Relieves chest pain and ischemia Improves the patient's quality of life Enable the patient to resume a normal lifestyle Lower the risk of a heart attack

Indications For CABG

Patients with blockages in coronary arteries Patients with angina Patients who cannot tolerate PTCA (Percutaneous transluminal coronary angioplasty ) and do not respond well to drug therapy

Contraindications For CABG

Aneurysms Valvular diseases Congenital diseases diseases of blood

Procedure
An endotracheal tube is inserted and secured by the anaesthetist and mechanical ventilation is started. General anaesthesia is maintained by a continuous very slow injection of Propofol. The chest is opened via a median sternotomy and the heart is examined by the surgeon involves creating a 6 to 8 inch incision in the chest (a thoractomy) . The bypass grafts are harvested frequent conduits are the internal thoracic arteries, radial arteries and saphenous veins. When harvesting is done, the patient is given heparin to prevent the blood from clotting. "on-pump", the surgeon sutures cannulae into the heart and instructs the perfusionist to start cardiopulmonary bypass (CPB). Once CPB is established, the surgeon places the aortic cross-clamp across the aorta and instructs the perfusionist to deliver cardioplegia to stop the heart and slow its metabolism

Procedure
One end of each graft is sewn on to the coronary arteries beyond the blockages and the other end is attached to the aorta. Chest tubes are placed in the mediastinal and pleural space to drain blood from around the heart and lungs. The sternum is wired together and the incisions are sutured closed. The patient is moved to the intensive care unit (ICU) to recover. Nurses in the ICU focus on recovering the patient by monitoring blood pressure, urine output and respiratory status as the patient is monitored for bleeding through the chest tubes. If there is chest tube clogging, Thus nurses closely monitor the chest tubes and under take methods to prevent clogging so bleeding can be monitored and complications can be prevented. After awakening and stabilizing in the ICU (approximately one day), the person is transferred to the cardiac surgery ward until ready to go home (approximately four days).

Explanation

Heart Lung Machine

Nursing Management
Pre operative Phase Intra operative Phase Post operative Phase

Pre operative Phase

Assessment Patient history Physical Examination (head to toe ) Diagnostic procedure

Patient History
Patient history of major illness, previous surgery, medications, and usage of drugs and smoking and drug history A systematic assessment of all systems performed ,with emphasis on cardiovascular functioning

Physical Examination
Functional status of the cardiovascular system determined by reviewing the patient symptoms , including past and present experience with chest pain ,hypertension, palpation ,cyanosis, breathing difficulty ,leg pain that occur with walking ,Orthopnea, peripheral edema.because alteration in cardiac function (cardiac out put can affect renal, respiratory, gastrointestinal , integumentary, hematological, and neurological functioning )

Physical Examination
General appearance and behavior. Vital signs Nutritional and fluid status ,weight, height Inspection and palpation of the heart ,noting the point of maximal impulses ,abnormal pulsation ,and thrills Auscultation of the heart ,noting pulse rate ,rhythm, and quality; S4 and S3 , murmur, and friction rib Jugular venous pressure Peripheral pulses Peripheral edema

Psychosocial Assessment
Meaning of the surgery to the patient and family Coping mechanisms that are being used Measures used in the past to deal with stress Anticipated changes in life style Support system in effect Fears regarding the present and future Knowledge and understanding of the surgical procedure, postoperative course and long term rehabilitation

Nursing Intervention
Explain all treatment and procedure done for the patient answering any question patient may have .present information at patient understanding level to reduce patient anxiety Orient patient to surrounding Assign the same nurse to care for patient when ever possible to provide consistency of care, enhance trust and reduce threat often associated with multiple care givers. Spend time with patient each shift to allow time for expression of feelings, provide emotional outlet and promote feeling of acceptance.

Intra operative Phase

Patient will receive general anesthesia ,be intubated , and placed on mechanical ventilator, the preoperative nurse are responsible for the patient safety and comfort. Some of the areas of intervention include positioning, the skin preparation wound care, and emotional support to the patient and family. Before chest incision is closed, chest tubes are positioned to evacuate air and drainage from the media sternum and the thoracic cavity .

Intra operative complication

Possible Intraoperative complication includes Dysrthmyais,Hemorrhage , Emobilization , Organ failure from shock , or adverse drug reaction.

Post Operative
GOAL: achieving or maintaining homodynamic stability and recovery form general anesthesia

Assessment
Neurological system Cardiac status Respiratory status Peripheral vascular status Monitor complication Renal function Pain Fluid and electrolyte

Complications
Decrease C/O Hypothermia Tachydysrythmias Cardiac failure Electrolyte imbalance Fluid overload HTN Bradycardia Acute renal failure Hepatic failure Infection

Nursing Diagnosis Related To CABG

Decrease cardiac output Impaired gas exchange Risk for imbalance fluid volume Acute pain Deficient knowledge

ANY QUESIONS

References
Medscape http://emedicine.medscape.com/article/1893992-overview

AHA http://my.americanheart.org/professional/General/2011-ACCFAHAGuideline-for-Coronary-Artery-Bypass-Graft-Surgery
Textbook Brunner and Siddhartha's Textbook of Medical-Surgical Nursing , 12th edition, Brunner and Siddhartha's Textbook of Medical-Surgical Nursing 2012

THANK YOU FOR GOOD LISTENING

KHALED MAHAJNA .RN FACULTY OF NURSING AL ISRA UNIVERSITY Mobile (+962)-78-6627008 E-mail Mahajna_kh@hotmail.com Facebook Khaled Mahajna