03-09-2016, 10:44 AM
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The Preoperative Phase
Information when conducting preoperative teaching with a patient scheduled for CABG surgery may include sights and sounds that will be experienced, invasive lines that will be inserted, anticipated sensations from preoperative medications, and anticipated length of the operation. During the preoperative teaching session, the nurse should also provide information related to postoperative expectations.
Reassurance that pain will be managed during the postoperative period is important to communicate to the patient and significant other. Teaching about incision splinting and availability of effective pain medications should be emphasized.
Patients should be informed that an endotracheal tube will probably be in place postoperatively, resulting in a temporary inability to speak. Assure the patient that a competent caregiver will be in close proximity during the immediate postoperative recovery period and will be able to anticipate and provide for needs. The patient should be assured that the endotracheal tube will be removed as soon as it is no longer needed.
Pulmonary care is an important part of the postoperative care of the patient after CABG surgery. Preoperative practice with the equipment (such as an incentive spirometer) that will be used postoperatively is helpful. Teaching in the preoperative period assists the patient to comprehend the necessity of coughing effectively in spite of incisional pain to achieve positive outcomes postoperatively. Early mobilization is effective in improving postoperative pulmonary outcomes. Preoperative teaching might include information related to the potential for mobilization to a chair during the first evening postoperatively.
The significant other may be anxious and this may intensify as his/her loved one is taken to surgery.
Postoperative Management of Hemodynamics
Intraoperative myocardial ischemia is a potential cause of low cardiac output (CO) during the immediate postoperative period. The nurse must continually assess the patient for cardiac dysfunction and hemodynamic instability. The receiving nurse must intensively monitor the interrelationship between heart rhythm and rate, preload, afterload, contractility, and myocardial compliance to achieve this outcome. Preload is determined by the volume of blood returning to the right atrium as well as by myocardial compliance. Preload is a measurement of end diastolic pressure. Afterload is the force the left ventricle must overcome to eject blood during systole. It is determined, in part, by myocardial contractility and systemic vascular resistance.
Myocardial contractility refers to the force generated by the heart during systole.Myocardial compliance is the ease with which the heart distends during diastole.
Blood pressure must be maintained within ordered parameters to provide tissue perfusion and prevent disruption of the surgical anastomoses. BP is CO multiplied by systemic vascular resistance (SVR). The nurse must monitor the volume in the system, which is reflected by the right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP).
If the BP is too low, there is either too little volume (preload), a decrease in contractility, or the SVR is too low (the patient's blood vessels are dilated). If the BP, CO, and RAP/PCWP are all low, the patient probably needs volume . Volume is generally replaced as needed with a colloid such as hetastarch unless the hematocrit is low and then volume may be replaced with packed red blood cells. If the BP and CO are low but the PCWP is high, the patient may be experiencing decreased contractility and inotropic support may be instituted .
Low BP can be temporarily increased by turning off positive end expiratory pressure (to decrease intrathoracic pressure and augment preload) and by position changes. The patient should be put in the supine position with legs elevated to allow the BP to increase until the cause of the low BP can be determined and corrective measures are taken. Although not universally utilized, some institutions continue to place patients in the Trendelenburg position. The Trendelenburg position can offer symptomatic relief from low BP, especially in the early postoperative phase, by shifting volume from the legs to the chest and increasing preload. The positive changes identified with Trendelenburg positioning seemed to provide only temporary improvement in the clinical .
When bleeding occurs there is potential for the blood to accumulate in the pericardium, and therefore, the nurse must be cognizant of the potential for cardiac tamponade. The clinical manifestations of cardiac tamponade include lack of chest tube drainage, decreased BP, narrowed pulse pressure, increased heart rate, jugular venous distention, elevated central venous pressure, and muffled heart sounds. Emergency reoperation would be required.
Postoperative Neurologic Management
Patients who require coronary artery bypass surgery are at an increased risk for neurologic complications. Stroke can be caused by hypoperfusion or an embolic event during or after surgery. Manipulation of the aorta has been implicated in embolic events. Other risk factors for stroke may include age, previous stroke, carotid bruits, and hypertension. The incidence of stroke is approximately 2.5%.
must continue because the risk of stroke does not end with the operation. The nurse should be particularly astute to neurologic assessment in the postoperative period. When the patient is admitted to the intensive care unit, he/she will likely be intubated and unconscious. The effects of the neuromuscular blocking agents will be apparent. Pupils should be assessed initially, however, normal size and reactivity may not return until agents utilized intraoperatively have been metabolized. Over the first few hours after surgery, the results of the neurologic assessment should improve gradually. By the time the patient is ready for extubation, he/she should follow commands and have equal movement and strength of the extremities with neurologic function approaching the patient's normal.