Nursing care of clients

before and after CABG

Shejila C H
Professor
MIMS College of Nursing
Malappuram
Learning outcome
At the end of the lecture students will be able to
List down indications of CABG.
Explain cardiopulmonary bypass and cardioplegia.
Describe the preoperative nursing care of patient
undergoing CABG
Explain the specific patient education before CABG
Describe the post operative nursing care of patients
after CABG
Explain the specific client instructions followingCABG
Coronary artery bypass graft
Indications
• Angina that cannot be controlled by medical therapies
• Unstable angina
• A positive exercise tolerance test and lesions or blockage that cannot be
treated by PCI
• A left main coronary artery lesion or blockage of more than 60%
• Blockage of two or three coronary arteries, one of which is the proximal
left anterior descending artery
• Left ventricular dysfunction with blockages in two or more coronary
arteries
• Complications from or unsuccessful PCIs , Previous CABG.
Procedure
A blood vessel, usually the saphenous vein or internal mammary artery is
harvested and anastomosed to the affected coronary artery thereby
bypassing the obstruction.
Coronary artery bypass graft
Cardiopulmonary bypass and cardioplegia
CPB is a system used to temporally perform the
functions of heart and lungs during operative
procedure on heart and great vessels
Cardioplegia
Is induction and maintenance of heart in an arrested
state using chilled solution infused into coronary
artery circulation
Cardiopulmonary bypass
Nursing care-pre operative
Assessment
Detailed health history
a) Risk factors
b) Allergies
c) Patients symptoms- past and present experiences with chest pain,
hypertension, palpitations, cyanosis, breathing difficulty (dyspnea)
, leg pain that occurs with walking (intermittent claudication) ,
orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema
d) Medications , use of drugs , alcohol , tobacco
e) Major illnesses
f) Previous surgeries
Assessment
Physical assessment
Specific cardiovascular assessment &Review of systems- renal,
respiratory, gastrointestinal, integumentary, hematologic, and
neurologic functioning
Specific emphasis on
General appearance and behavior
Vital signs
Nutritional and fluid status ,weight and height
Inspection and palpation of heart
Auscultation of heart
Jugular venous pressure ,peripheral pulses, peripheral edema
Assessment
Psychosocial assessment
Assessment of level of anxiety
Coping mechanisms
Anticipated changes in lifestyle
Support systems
Knowledge and understanding of surgical
procedure ,post operative course and rehabilitation
PREOPERATIVE PREPARATION
LEGAL PREPARATION- Informed consent

BOWEL PREPARATION-enema ,fasting

PHYSICAL PREPARATION
Preoperative nursing diagnoses
Fear related to surgical procedure, its uncertain
outcome and threat to well being
Deficient knowledge regarding the surgical procedure
and post operative course
High risk for complications – angina, cardiac
arrhythmias
Preoperative goals
Reduce fear
Learn about surgical procedure and post op course
Protect patient from pre operative complications
Nursing interventions with rationale
Reducing fear
Encourage patient to Helps to remove
ventilate his fears and misconceptions
concerns Decrease the chance of
Explain preoperative post operative
sedation,anesthetic,an complications ,promot
d post operative pain es smooth anesthesia
medications induction involvement
Explore the feelings of in care
family members Help to cope ,support,
participate in post op
and rehab care
Nursing interventions
Deficient knowledge regarding the
surgical procedure and post
operative course
Give information to client and Decrease the chance of
family about post operative
hospitalisation,surgery
complications ,promotes
(pre and post op care, length of
surgery ,expected pain and smooth anesthesia
discomfort, visiting hours, induction involvement in
procedures in critical care care
unit)recovery phase (length of
hospitalisation,when normal
Help to cope ,support,
activities can be participate in post op and
resumed ,changes in life style. rehab care
Nursing interventions
High risk for complications
angina,cardiac arrhythmias
Administer anti anginal
Helps to relieve anginal
medications
pain
Administer oxygen and
Reduces cardiac
Follow the treatment
regimen workload
Emotional support and
education Eliminate fear and
Administer Anxiolytic agents anxiety otherwise which
can cause complications
Evaluation
Demonstrates reduced fear
Learns about surgical procedure and postoperative
course
Shows no evidence of complications
Specific preoperative client teaching
Preoperative preparation
Shaving from chin to toes
Shower with antimicrobial agent
Preoperative studies-complete blood count,
electrolyte studies, cardiac
enzymes,BUN,creatinine,bleeding studies, arterial
blood gases, chest x-ray, pulmonary function tests,
blood typing and cross matching
Nil per oral status,pre operative medications-like use
of sedatives, prophylactic antibiotics
Specific client teaching
Introduction to intensive care unit
Noisy and busy environment and limitation in family visits
Equipments and procedures
Endotracheal tube for 8-24 hrs,unable to speak, feelings of breathless when
suctioned, use of restraints to keep person from not pulling out tube
Foley catheter
Arterial line and pulmonary artery catheter
Chest tubes
Pacemaker wires
Nasogastic tube
Iv lines
Monitors
Specific client teaching
Deep breathing and coughing
Use of incentive spirometer
Foot exercises
Turning
Early ambulation
Pain medication available
Post operative nursing care
Focus of care
Monitoring of cardiopulmonary status
Pain management
Wound care
Progressive activity
Nutrition
Education about medication& risk factor modification
Post op nursing care
Assessment
Hourly for at least 12 hours
Complete assessment of all systems
Neurological status- LOC, pupil size and reaction,
movement of extremities,reflexes,hand grip strength
Cardiac status-heart rate and rhythm, heart sounds
pressures like ABP,CVP,PAP.cardiac output, peripheral
perfusion, chest tube output oxygen saturation
Respiratory status- chest movement, breath sounds,
ventillator settings,respiratory rate,arterial blood gases
Post op nursing care
Peripheral vascular status- peripheral pulses, colour of
skin, nail beds,mucosa,lips,and ear lobes, skin
temperature,edema,conditions of dressing and
invasive lines
Renal function-urinary output, urine specific gravity,
and osmolality
GI function-bowel sounds, presence and function of
NG tube, presence of abdominal distension
Fluid and electrolyte status- intake, output from all
drainage tubings,indications of electrolyte imbalance
Post op nursing care
Pain –nature ,type,location,duration,response to
analgesics
Observing all equipments and tubes to determine
whether they are functioning properly
Endotracheal tube,ventillator,SpO2 monitor, arterial
and IV lines cardiac monitor, chest tubes urinary
drainage system
Post op nursing care
Assessing complications
• Cardiac complications
Decreased cardiac output,hypovolemia,persistent bleeding,
cardiac tamponade, fluid overload,
hypothermia,hypertension,arrythmias,bradycardia cardiac
failure ,MI,
Pulmonary complications
Impaired gas exchange
Atelectasis
Pneumonia
Pleural effusion
Post op nursing care
Neurologic complication
Transient ischemic attacks
Stroke
Impaired level of consciousness
• Renal complications and electrolyte imbalances
Renal failure
Renal tubular necrosis
Electrolyte imbalances like potassium, sodium,
calcium, magnesium and blood glucose
Post op nursing care
GI complications
Hepatic failure,GI hemorrhage, paralytic ileus,small
bowel obstruction, pancreatitis, cholecystitis
• Infection
Respiratory, urinary, wound infection
Nursing diagnoses
Decreased cardiac output related to blood
loss ,compromised myocardial function and
dysrhythmias
Impaired gas exchange related to trauma of chest
surgery
Acute pain related to surgical trauma and pleural
irritation caused by chest tubes
Ineffective tissue perfusion (renal, cerebral,
cardiopulmonary,gastrointestinal,peripheral )related
todecreaed cardiac output,hemolysis,vasopressor drug
therapy)
Nursing diagnoses
Ineffective thermoregulation related to infection or
postpericardiotomy syndrome
Disturbed sensory perception related to excessive
environmental stimuli, sleep deprivation, electrolyte
imbalance
Risk for imbalanced fluid volume and electrolyte
imbalance related to alterations in blood volume
Risk for complications –
cardiac,pulmonary,neurologic,GI,renal,infection..
Knowledge deficit regarding self care activities
Goals
Restoration of cardiac output
Adequate gas exchange
Relief of pain
Maintenance of adequate tissue perfusion
Maintenance of normal body temperature
Reduction of symptoms of sensory perceptual alterations
Maintenance of fluid electrolyte balance
Absence of complications
Learning self care activities
Nursing interventions and rationale
Restoring cardiac output
Monitor cardiovascular status-
Assess BP every 15 minutes to determine effectiveness of
cardiac output
Auscultate heart sounds to detect cardiac tamponade,
pericarditis
Assess peripheral pulses to detect adequate cardiac
output
Monitor PAP,CVP to detect heart failure or cardiac
tamponade
Nursing interventions
Monitor ECG to detect development of arrhythmias
Monitor intake and output to detect fluid deficit
which alter CO
Observe for bleeding to prevent complications
Monitor shivering to prevent increase in BP and CO
Monitor chest tube drainage to detect hypovolemia
and bleeding
Nursing interventions
Adequate gas exchange
Maintain mechanical ventilation to decrease work of heart and
provide airway in event of complications
Monitor ABG to detect acidosis
Auscultate lung sounds to detect pulmonary edema
Sedate the patient adequately to tolerate ET and cope with
ventillatory sensations
Suction tracheobronchial secretions to prevent hypoxia and infection
Assist with extubation to decrease risk of pulmonary infections
After extubation Promote deep breathing, coughing and turning to
prevent atelectasis and aid in lung expansion
Nursing interventions
Relieving pain
Record characteristics of pain to determine cause and plan
actions
Splint chest incision with movements,coughing,turning to
increase comfort and stabilizes sternum
Turn ,reposition every 2 hrs to relieve muscle stiffness
Instruct to take deep breath before movement, exhale slowly
during movement to keep muscles relaxed and minimizing
pain
Administer routine pain medication to promote rest and
decrease oxygen consumption caused by pain
Nursing interventions
Maintenance of tissue perfusion
Assess renal function to detect deteriorating renal
status
Monitor LOC ,pupillary changes to determine adequacy
of cerebral perfusion
Monitor peripheral pulses to assess arterial obstruction
observe for chest pain,respiratory distress,abdominal
pain decreased urinary output,one sided weakness to
detect thromoemboli formation
Nursing interventions
Maintenance of body temperature
Assess temperature every hour to detect inflammatory
process
Use aseptic technique to decrease risk of infection
Observe symptoms of post cardiotomy syndrome to
prevent complications
Administer antibiotics to prevent infections
Administer anti-inflammatory drugs to relieve
symptoms of inflammation
Nursing interventions
Reduction of symptoms of sensory perceptual
imbalance
Explain all procedures and need for cooperation to
prevent anxiety and fear
Plan nursing care to provide uninterrupted sleep
Decrease sleep preventing stimuli to promote sleep
Teach relaxation techniques to divert from unwanted
fear and anxiety
Encourage self care to get support and coping
Encourage family visits to relieve anxiety
Nursing interventions
Fluid and electrolyte balance
Keep intake output flow sheets to detect negative and
positive fluid balance
Assess BP, weight ,electrolytes ,skin turgor , CVP to
detect dehydration
Note electrolyte imbalances –hypokalemia,hyperkalemia
hyponatremia,hypocalcemia,hyperglycemia to prevent
complications
Nursing interventions
Absence of complications
Assess cardiac status
Pulmonary status
Neurologic status
Renal function GI function helps in early
detection of complications
Signs of infection
Hemorrhage
Continuous monitoring
Nursing interventions
Learn self care
Develop teaching plan on activity
progression,diet,exercise,deep breathing and
coughing, medication regime, life style changes to give
teaching according to client needs
Provide verbal and written instructions to promote
learning and clarification of misinformation
Involve family in teaching to get support in care
Evaluation
Maintains adequate cardiac output
Maintains adequate gas exchange
Experiences relief of pain
Maintains adequate tissue perfusion
Maintain fluid and electrolyte balance
Maintains normal body temperature
Experiences decreased symptoms of sensory perception
disturbances
Exhibit no signs of complication
Perform self care activities
Specific client education after coronary
bypass surgery
Coughing and deep breathing
Bathing-shower after 5 days, don't use too hot water
Wound care-keep clean and dry
Warning signs-temperature more than 101 degree
Fahrenheit for 24 hrs,seperation of suture line,
drainage or bad smell from suture line, redness or
swelling
Supportive stockings –wear everyday, wash in warm
soapy water
Getting out of bed everyday ,and walk
Specific education
Lifting and straining-don’t lift objects more than 10
pounds for first 2-3 months, avoid straining -during
bowel movement
Sexual activity-if client is able to climb up 1 flight of
stairs ,can resume sexual activity
Travelling-don’t drive for 4-6 weeks, check with
physician before long trip
Work-return to work based on physical condition, stay
home if work involves straneous activities, stop work
sit or lie down if chest pain, dizziness or trouble
breathing occurs
Specific education
Chest pain-use nitroglycerine under tongue
Medications –how to take, never take more or less medicine, never stop
taking medicines
Life style and risk factors
Drinking-no drinking if taking sleeping pills, or pain pills
Diet –low fat
Smoking-stop
Control of BP
Control cholesterol
Weight –control weight, recorded everyday, notify gain of 3 pounds in one
day
Stress-teach measures to control stress
Exercises -regular
Remind to keep all appointments with physician
Case discussion
Amina 65 yrs, who had undergone open CABG 24
hours ago, has a urine output averaging 20ml/hour for
2 hours. Amina received a single bolus of 500ml of
intravenous fluid. Urine output for the subsequent
hour was 25ml. Daily laboratory results indicate that
the blood urea nitrogen is 45 mg/dl. and the serum
creatinine is 2.2mg/dl. Temperature is 37.2◦C orally.
The white blood cell count is 7500 cells/mm3.
Case discussion
List down the post operative complications that can
develop in Amina.
Identify priority nursing diagnoses and develop a
nursing care plan for her
Prepare a health education plan for her
References
Smeltzer, S.C. & Bare, B. G. (2004) Brunner & Suddarth’s
Textbook of Medical –Surgical Nursing. (10th Ed.).
Philadelphia: LippincottWilliams & Wilkins
Williams ,L.S & Hopper, P.D (2007)understanding medical
surgical nursing.(3rd Ed). Philadelphia: F.A Davis Company.
Lewis,Heitkemper et al (2005)medical surgical nursing
assessment and management of clinical problems
(ed.7)St.Louis :Elsevier publications