Lesson 1.4
NURSING CARE OF THE CARDIOVASCULAR SURGICAL PATIENT

1-31.  INTRODUCTION

Through the use of modern techniques, it is possible for surgeons not only to repair damage or deformity of the large blood vessels but also to stop the heart, open it, and perform necessary surgery there. For purposes of discussion of nursing care, cardiovascular surgical patients may be considered under three general conditions: (1) those whose hearts have been opened or entered, as in surgery of the heart valves; (2) those in whom surgery is confined to the great vessels or to the exterior of the heart, as in coarctation of the aorta, patent ductus arteriosus, aneurisms, anastamoses, and non perforating wounds of the myocardium; and (3) those in whom surgery involves the major coronary arteries.

1-32.  PREOPERATIVE CARE

a. Most patients scheduled for cardiovascular surgery enter the hospital several days prior to surgery. This allows for adequate time to prepare the patient for what lies ahead and adequate time for the staff to develop a rapport with the patient.  Establishing a trusting relationship with the patient will provide him with emotional support.

b. A thorough assessment of the patient must be made. Many members of the health care team will be involved in this phase of preparation.

(1) The physician must complete a thorough physical examination and patient history. He orders the lab work, X-rays, ECGs, and other studies that must be done to obtain baseline data on the patient's immediate preopcondition.

(2) A nursing assessment of the patient must be done. This involves assessing the physical, psychological, social, and spiritual needs of the patient.

(3) The dietician may visit the patient to do a nutritional evaluation and teach the patient about his new postoperative diet.

(4) The physical therapist may visit the patient to instruct him in the postoperative procedures for his rehabilitation.  Explanations will be given regarding the importance of advancing activity under the supervision of the staff, and exercise routines will be taught.

(5) An assessment must be made of the patient's coping mechanisms. This may be done by the chaplain, the psychologist, or most commonly, by the nursing personnel. Poor coping mechanisms mean increased anxiety for the patient, and increased anxiety leads to a slower recovery. Early identification of this problem will allow the nursing staff to make provisions for it in the nursing plan of care.

c. The nursing considerations in preoperative management include the following areas.

(1) The nursing staff executes the physician's orders, gathers data, and keeps the physician up to date regarding the patient's status.

(2) Patient education is implemented. The patient is instructed about his postoperative routine and the importance of his participation and cooperation during the postoperative course.

(3) The patient must be fully oriented to the postoperative environment.

This includes familiarization with the monitors, machines, and equipment that will be used during the postoperative period. If possible, give the patient a tour of the CCU and allow him to meet some of the nursing personnel.

(4) Reduce patient anxiety by establishing a friendly informative, caring relationship with the patient.

1-33.  POSTOPERATIVE CARE

Postoperative care for patients who have had surgery of the heart or great vessels is generally much the same as that given to other chest surgery patients. A possible exception to this generalization is care for the patient who has had surgery of the coronary arteries (see paragraph 1-33d below). The first 48 hours following cardiovascular surgery are the most critical, and a high degree of alertness and skill in nursing care are essential if death is to be prevented. Intensified nursing care should continue for at least the first five postoperative days.

a. Vital Signs. Pulse, blood pressure, and respiration must be taken and recorded every 15 minutes until they stabilize, usually after 4-8 hours. In addition, cyanosis must be watched for and its cause corrected. A systolic pressure of only 80 or 90 in cardiovascular (CV) surgical patients is no cause for alarm as these patients tolerate the lower pressure well. The physician should be called immediately if the systolic pressure is below 80. The exception is the coronary artery surgical patient, whose pressure should be not more than 10 mm. below the preoperative pressure. The apical pulse, taken over the heart with a stethoscope, most immediately reflects the activity of the heart; however, the arterial pulse should be taken not only from the radial artery at the wrist, but also from arteries of all limbs to detect the presence of an embolus as early as possible. Temperatures outside the 97 to 102F range should be reported. Higher temperatures may be an indication of shock or cardiac decompensation. The respiratory character as well as the respiratory rate should be noted. Using the stethoscope aids in detecting changes in character. Changes noted should be reported promptly.

b. Oxygen Therapy. Oxygen is given by facemask, usually at the rate of 8 liters per minute. After the patient has fully reacted, a nasal cannula is substituted and oxygen is continued at 4 to 6 liters per minute until the physician orders discontinuance. Peripheral signs of cyanosis and ischemia must still be watched for, however. Mottling or blanching of the skin in an extremity--particularly if it is accompanied by other phenomena such as pain, numbness, tingling, or loss of motion--may indicate the presence of an embolus and should be immediately reported.

c. Psychological Considerations. Any signs of disorientation, such as failure to recognize a member of the family or familiar surroundings, should be reported. A transient state of depression may be expected in the CV surgical patient. In an occasional patient, the depression will degenerate into suicidal tendencies. Postoperative depression may be prevented or its intensity lessened through preoperative explanation of the upcoming procedure and sympathetic consideration of the patient's fears and concerns.

d. Positioning and Turning. Usually, the patient is kept in the dorsal recumbent position until his systolic pressure is more than 100. On specific orders from the physician, a CV surgical patient, other than one who has had coronary artery surgery, may be raised to a semi-Fowler position and may be turned from side to side every two hours. A blood pressure reading must be taken immediately before and 5 minutes after the patient is raised. If the blood pressure drops after the patient is raised, the head of the bed and the patient must be returned to horizontal for at least 30 minutes before the procedure is repeated. The coronary artery patient is usually kept in dorsal recumbent position for 48 hours before any attempt is made to change his position because, up to that time, turning the patient as little as 15 degrees to one side may cause a serious drop in blood pressure. When turning is permitted, the coronary artery patient should be turned from back to right side (and vice versa) every 2 hours.

e. Pain. Ribs that were retracted during surgery are the major sources of postoperative pain in the CV surgical patient. During the first 24 to 48 hours, Demerol is given on a schedule and in a quantity sufficient to keep him reasonably comfortable but not enough to depress his mental outlook and cough reflex. After this initial period, other causes for continued restlessness--such as oxygen deprivation, fear, and positional discomfort--should be looked for and corrected.

f. Cough. After stabilization, CV surgical patients should be encouraged to raise deeply lodged secretions by coughing with support in the same manner as other surgical patients. Such coughing is usually effective, but if it is not, endotracheal suctioning must be employed. Sometimes a mucolytic agent applied in aerosol form may be helpful.

g. Underwater Seal Drainage. Nursing care with regard to CV patients with underwater seal drainage is generally the same as that for other chest patients with such drainage equipment in place. Drainage of about 400 to 500 ml of bloody fluid is to be expected from heart surgery patients during the first 24 hours. Absence of drainage fluid in the water seal setup indicates that fluid may be accumulating in the thorax. Thus, drainage volume must be carefully observed and recorded.

h. Gastric Suction. Temporary gastric distention is a common occurrence in CV surgical patients. The stomach is intubated and suction applied to reduce distention and relieve any pressure exerted on the heart by the distended stomach.

i. Diet. With permission of the physician, fluids may be given as soon as the patient can tolerate them. The first fluids given should be lukewarm and should not be fruit juices, as they may cause nausea. Cardiovascular surgical patients are normally markedly thirsty, and they will drink large quantities of fluids. If fluid is retained, intake may have to be restricted. Nursing personnel must diligently monitor and record fluid intake and output. Also, it may be necessary to weigh the patient daily. The physician probably will permit returning the patient to a soft or normal diet as soon as the patient desires solid food. Solid food should be withheld from the coronary artery surgery patient until abdominal cramps and gas no longer persist.

j. Exercise. The patient, upon regaining consciousness, is encouraged to breathe deeply through the nose deliberately and quietly to ventilate and expand the lungs. Care must be taken not to tire the patient. Other voluntary body movement and exercise are encouraged after the first 24 hours. The patient is encouraged to comb his hair, reach for objects within normal reach, and then use a pull to raise himself. A pull may be made from wide gauze attached to the foot of the bed and extending to within the patient's reach. A T-handle may be inserted or a knot tied in the end of the pull to facilitate easier grasping. From about the 5th to the 8th day, as determined by the physician, the patient is allowed to dangle his feet for gradually increasing lengths of time, then gradually allowed out of bed more and more until the patient is fully mobile, usually by the 12th to 14th day.

1-34.  COMPLICATIONS OF CARDIOVASCULAR SURGERY

As has been stated above, the first 48 postoperative hours are the most critical, and intensive care should be continued for several days until the patient is out of grave danger. Respiratory problems, hemorrhage, and shock are problems associated with any major insult to the body. The following paragraphs discuss complications associated with insult to the CV system in particular.

1-35.  THROMBOPHLEBITIS

Thrombophlebitis is inflammation of a vein with blood clot formation. Venous stasis (slowing of venous blood circulation) and pressure or other injury to vein walls predisposes its development. The most common sites for development of thrombophlebitis are in the veins of the pelvis and legs. A postoperative patient or any other individual who has remained still for hours at a time with relaxed muscles and a resultant slowing of venous circulation in the legs is particularly liable to develop thrombophlebitis. When inactivity is combined with pressure on the popliteal space and the calf of the leg, the possibility of developing thrombophlebitis increases.

a. Signs and Symptoms of Thrombophlebitis.

(1) Cramping pain in the calf.

(2) Possible redness, warmth, and swelling along the course of the involved vein.

(3) Pain that may appear only on dorsiflexion of the foot.

b. Nursing Implications.

(1) Do not, under any circumstance, rub or massage the affected limb.

(2) Place the patient on immediate bed rest and notify the RN.

(3) Keep the affected limb horizontal and at rest until the physician has examined the patient and ordered specific treatment. Support the entire limb from the thigh to the ankle on pillows, keeping the limb level unless otherwise ordered. Orders for treatment may include elevation and application of continuous massive warm, moist packs to the entire limb.

(4) Use a bed cradle to prevent any pressure from the bed linen.

(5) Be alert to any complaint or other evidence of respiratory difficulty or chest pain. A clot which is adherent to the vein wall, or a portion of a clot, can become dislodged and be carried in the circulation as an embolus to distant and smaller arterial blood vessels in the lungs. Sudden dyspnea, violent coughing, or severe chest pain may be the first sign of embolism.

(6) Discontinue routine postoperative exercise, ambulation, deep breathing, and coughing measures until the physician has indicated which measures are to be resumed and which precautions are to be taken.

(7) Carry out all subsequent treatment and nursing care measures in a manner that will avoid abrupt movements and any strain on the part of the patient.

(8) When ordered, apply anti-embolism hose or intermittent external pneumatic compression system to give support and aid venous circulation.

(9) When the patient is allowed out of bed, remind him to alternate walking and resting with feet propped on a stool to avoid pressure in the popliteal space. Prolonged standing or sitting with no movement must be avoided. Check to see that the edge of the chair seat does not press the popliteal space and that the patient does not sit with crossed legs.

1-36.  EMBOLISM

An embolus is a blood clot or other foreign particle (fat globule or air bubble) floating in the bloodstream. The embolus is usually undetectable until it suddenly lodges in an arterial blood vessel. This may occur when the patient is apparently convalescing and progressing normally. If the embolus is sufficiently large and the arterial vessel which it obstructs supplies a vital area in the lungs, heart, or brain, the patient may die before any symptoms of embolism are detectable. A special type of embolism, pulmonary embolism, is caused by the obstruction of a pulmonary artery by an embolus. The most frequent cause of a postoperative pulmonary embolism is a thrombosed vein in the pelvis or lower extremities. Therefore, measures to prevent development of thrombophlebitis are the most important ones to take to prevent the possibly fatal complication of pulmonary embolism.

a. Signs and Symptoms. NOTE: May or may not be observable.

(1) Sudden signs of shock and collapse.

(2) Sudden, sharp, stabbing chest pain.

(3) Sudden violent coughing and hemoptysis (spitting of blood).

(4) Pain, blanching, numbness, or coldness in an extremity.

b. Nursing Implications.

(1) Notify the registered nurse (RN) immediately.

(2) Ensure absolute bed rest. Elevate head of bed to relieve respiratory distress.

(3) Prepare to start oxygen by mask at 6 to 8 liters per minute.

(4) Take and record blood pressure, pulse, and respiration.

(5) Prepare to give medication by injection to relieve pain and acute apprehension. A narcotic drug such as morphine sulfate or meperidine hydrochloride is often ordered.

(6) Prepare to continue intensive nursing care and constant observation. (The total care of the patient who survives a pulmonary embolism is similar to that of a patient who has had a myocardial infarction.)

1-37.  ANTICOAGULANT DRUG THERAPY IN THROMBOPHLEBITIS AND EMBOLISM

a. General. Anticoagulant drugs such as heparin sodium and coumadin compounds lessen the tendency of blood to clot. They are frequently ordered as a part of the medical management of patients who have developed thrombophlebitis or who have survived an embolism.

(1) These drugs do not dissolve thrombi that have already formed, but are an important treatment measure to prevent extension of a clot within a blood vessel or to prevent further intravascular clot formation.

(2) Anticoagulant drugs act by prolonging the clotting time of blood.

(3) Since a patient who has once developed thrombophlebitis may have a recurrence, he may be continued on an anticoagulant drug indefinitely as a prophylactic measure.

b. Medical Considerations.

(1) Drug dosage is regulated very carefully by the physician, in relation to the individual patient's prothrombin determination. (Prothrombin determination is a special blood test.)

(2) Certain drugs should not be given with anticoagulants. Aspirin and aspirin-like drugs increase the effect of the anticoagulant. Phenobarbital and butazolidine decrease the effects.

c. Nursing Implications.

(1) Nursing personnel have a responsibility to recognize that any patient receiving an anticoagulant drug must be closely observed for bleeding.

(2) Bleeding may occur from the mouth, nose, urinary tract, or rectum.

(3) Patients receiving anticoagulant therapy should be encouraged to use a soft bristle toothbrush and an electric razor instead of a blade.

(4) Local policy often dictates that only the RN may administer anticoagulant drugs. This is due to the potential hazards and complicated dosage orders.

1-38.  CARDIAC TAMPONADE

Bleeding into the pericardial sac, or accumulation of fluid in the pericardial sac, results in compression of the heart. This compression reduces heart movement, prevents adequate filling of the ventricles, and obstructs venous return to the heart.

This condition, called cardiac tamponade, is an emergency that requires prompt relief to prevent death from circulatory failure.

a. Signs and Symptoms.

(1) Distention of the neck veins.

(2) Weak pulse.

(3) Low pulse pressure.

NOTE: Delayed distention of the neck veins should not be confused with the transitory distention seen postoperatively as the patient throws off unconsciousness produced by anesthesia. This distention is usually the result of straining.

b. Nursing Implications.

(1) Report signs and symptoms to the RN immediately.

(2) Monitor pulse and blood pressure.

(3) Administer oxygen as ordered for dyspnea.

(4) Assist with diagnostic procedures such as chest X-ray, ECG, or cardiac catheterization.

(5) Assist with procedures to relieve pressure and remove fluid such as thoracotomy or needle aspiration of the pericardial cavity.

1-39.  RENAL FAILURE

a. Impairment of renal function may be caused by decreased cardiac output associated with open-heart surgery or by red blood count (RBC) hemolysis caused by the trauma of cardiopulmonary bypass.

b. Nursing implications when renal failure is suspected include the following:

(1) Strict and accurate recording of intake and output.

(2) Measurement of urine output on an hourly basis.

(3) If a urine output of less than 20 cc/hr is obtained, immediate notification should be made to the RN.

(4) Routine specific gravity of urine should be performed and recorded. (Specific gravity provides information relative to kidney function.)

1-40.  MYOCARDIAL INFARCTION

a. A MI may occur during the postoperative period. Symptoms, however, may be masked by the postoperative pain being experienced by the patient.

b. Nursing implications include the following:

(1) A careful assessment of the patient's pain must be made in order to differentiate between routine postoperative discomfort and the pain associated with a myocardial infarction.

(2) If MI has occurred, nursing management of the patient will encompass both postoperative and post-MI nursing care considerations.