Anastomosis: Surgical connection created between tubular struc- tures, such as blood vessels, that are grafted into the coronary arteries to create a bypass channel for circulation around a blocked artery.
Cardiopulmonary bypass (CPB) (also called heart-lung ma- chine): Mechanical means of circulating and oxygenating the blood through the body when it’s diverted from the heart and lungs. The heart’s beating is stopped so the surgeon can per- form the bypass procedure on a still heart.
Coronary artery bypass grafting (CABG): Procedure in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart.
These grafts usually come from the client’s own arteries and
G L O S S A R Y
veins located in the leg (saphenous vein), internal mammary artery (IMA), or internal thoracic artery (ITA). The graft goes around the blocked artery (or arteries) to create new pathways for oxygen-rich blood to flow to the heart (Cleveland Clinic, 2013).
Minimally invasive direct coronary bypass (MIDCAB): Re- quires a smaller incision and may be done for CABG and some valve remodeling and replacement procedures.
Off-pump coronary artery bypass (OPCAB) (also called off-pump coronary revascularization): Similar to the conventional CABG procedure. OPCAB still uses a medial sternotomy; however, CPB pump is no longer employed.
Off-pump procedures can offer certain advantages in POTENTIAL CONSIDERATIONSfollowing discharge from care setting (dependent on client’s age, physical condition and presence of complications, personal resources, and life responsibilities)
•Activity Intolerance—imbalance between oxygen supply and demand
•ineffective Self-Health Management—complexity of therapeutic regimen, decisional conflicts, economic difficulties, inadequate number of cues to action
CHAPTER 4CARDIOVASCULAR—CARDIAC SURGERY
Care Setting
Client is cared for at inpatient acute hospital on a surgical or post-intensive care unit (ICU) step-down unit.
Related Concerns
Angina, page 67
Heart failure: chronic, page 43
Dysrhythmias, page 87 Myocardial infarction, page 75 Pneumothorax/hemothorax, page 150 Psychosocial aspects of care, page 729 Surgical intervention, page 762
Transplantation considerations—postoperative and lifelong, page 719
low-risk populations, such as decreased cost, reduced length of stay, reduced postoperative complications, and avoidance of blood transfusions. They also reduce surgical trauma to the client as well as risk of stroke and kidney failure.
Percutaneous transmyocardial revascularization (PTMR) (also called transmyocardial laser revascularization, or TMR): Laser surgery that opens tiny new pathways within the heart muscle to treat the symptoms of angina in a client who cannot withstand more conventional treatments such as by- pass surgery or balloon angioplasty.
G L O S S A R Y
(continued)Robotic-assisted coronary artery bypass (RACAB): Surgeon views the procedure on a video screen, uses a robot to per- form the bypass, and has no direct contact with the client.
Sternotomy: Surgical incision made in the breastbone (mediastinum).
Totally endoscopic coronary artery bypass (TECAB): Ro- botic-assisted procedure in which small-port incisions are made in intercostal spaces. TECAB is performed on the beat- ing heart using a stabilization device that holds the anastomo- sis site steady and removes the need for CPB.
Client Assessment Database
D I A G N O S T I C D I V I S I O N M AY R E P O R T
A
CTIVITY/R
EST•Exercise intolerance
•Generalized weakness, fatigue
•Inability to perform expected or usual life activities
•Insomnia and sleep disturbances
C
IRCULATION•History of recent or acute MI (three or more), vessel coronary artery disease, valvular heart disease, hypertension
•History of inherited clotting disorders, such as hemophilia, and acquired clotting disorders, such as acute lymphocytic leukemia or lupus (which can affect postoperative bleeding)
•History of abnormal bleeding with previous surgeries, dental procedures, or childbirth
•Current use of antithrombotic drugs, including those that inhibit the production of clotting factors in the liver, such as warfarin (Coumadin); those that interfere with blood clotting by block- ing thrombin activity, such as heparin and lepirudin (Refludan);
and antiplatelet drugs, such as aspirin, clopidogrel (Plavix), tirofiban (Aggrastat), and eptifibatide (Integrilin), which keep platelets from aggregating into clots. Note:Cardiac patients tak- ing these drugs preoperatively require various interventions to ensure their safety for CPB and to reduce postoperative bleed- ing complications
•Recent use of over-the-counter (OTC) drugs, such as ibuprofen, and dietary supplements, such as vitamin E, garlic, ginseng, and ginkgo (can inhibit clotting)
•Abnormal heart rate, blood pressure (BP) changes with activity
•Exertional dyspnea
•Electrocardiogram (ECG) changes and dysrhythmias with activity
•Variations in BP, heart rate and rhythm
•Abnormal heart sounds: S3/S4, murmurs
•Pallor and cyanosis of skin or mucous membranes
•Cool and clammy skin
•Edema, jugular vein distention (JVD)
•Diminished peripheral pulses
•Abnormal breath sounds, such as crackles
•Restlessness and other changes in mentation or sensorium (severe cardiac decompensation)
M AY E X H I B I T
The preoperative data presented here depend on the specific disease process and underlying cardiac condition and reserve.
(continues on page 100)
D I A G N O S T I C D I V I S I O N M AY R E P O R T
(continued)E
GOI
NTEGRITY•Feeling frightened, apprehensive, or helpless
•Distress over current events
•Fear of death or eventual outcome of surgery or possible complications
•Fear about changes in lifestyle and role functioning
F
OOD/F
LUID•Change in weight
•Loss of appetite
•Nausea or vomiting
•Change in urine frequency or amount
N
EUROSENSORY•Fainting spells, vertigo
P
AIN/D
ISCOMFORT•Chest pain, angina
R
ESPIRATION•Shortness of breath
S
AFETY•Infectious episode with valvular involvement or myopathy
T
EACHING/L
EARNING•Familial risk factors of diabetes, heart disease, hypertension, strokes
•Use of various cardiovascular drugs
•Failure to improve
P
OSTOPERATIVEA
SSESSMENT Pain/Discomfort•Incisional discomfort
•Pain or paresthesia of shoulders, arms, hands, legs
•Respiration: Inability to cough or take a deep breath
•Safety: Oozing or bleeding from chest or donor site incisions
T
EACHING/L
EARNING•Modifiable risk factors for sternal wound infection, such as obesity, diabetes, and smoking
•Postoperative incision care to minimize or prevent infection
•Apprehension, restlessness
•Facial or general tension
•Withdrawal and lack of eye contact
•Focus on self, hostility, anger, crying
•Weight gain or loss
•Dry skin, poor skin turgor
•Postural hypotension
•Edema—generalized, dependent, pitting
•Changes in orientation or usual response to stimuli
•Restlessness, irritability, apathy
•Dyspnea
•Abnormal breath sounds, such as crackles
•Productive cough
•Guarding of incisional areas
•Facial mask of pain, grimacing
•Distraction behaviors, moaning, restlessness
•Changes in BP, pulse, respiratory rate
•Decreased chest expansion
•Splinting or muscle guarding
•Dyspnea—normal response to thoracotomy
•Areas of diminished or absent breath sounds (atelectasis)
•Changes in arterial blood gas (ABG) levels or pulse oximetry
M AY E X H I B I T
(continued)Client Assessment Database
(continued)CHAPTER 4CARDIOVASCULAR—CARDIAC SURGERY
T E S T
W H Y I T I S D O N E B
LOODT
ESTS•Hemoglobin (Hgb) and hematocrit (Hct): To identify red blood cell (RBC) and fluid replacement needs.
•Coagulation studies:Various studies may be done, such as platelet count and bleeding and clotting time.
•Electrolytes:A substance that, in solution, conducts an electric current and is decomposed by its passage. Sodium (Na), potas- sium (K+), and calcium (Ca) are common electrolytes.
•Arterial blood gases (ABGs):Assessment of levels of oxygen (PaO2) and carbon dioxide (PaCO2)
•Blood urea nitrogen (BUN) and creatinine (Cr):Elevated BUN can occur with dehydration, shock due to blood loss, or any condition that decreases blood flow to the kidneys.
•Glucose:Blood glucose levels should be controlled in all patients with diabetes to avoid hyperglycemia perioperatively.
•Cardiac enzyme and isoenzymes Troponin 1 (cTnl) and Troponin T (cTnT):Contractile proteins found in the myo - cardium with nearly absolute myocardial tissue specificity, as well as high sensitivity. Troponins increase within 3 to 4 hours of myocardial injury.
O
THERD
IAGNOSTICS
TUDIES•Chest x-ray: Evaluates organs and structures within the chest.
•Electrocardiogram (ECG):Record of the electrical activity of the heart.
Whether heart surgery is performed on or off CPB equipment, clients develop moderate hemodilution from the fluids given perioperatively, thus lowering the Hct and platelet count. A low Hgb reduces oxygen-carrying capacity and indicates need for RBC replacement. Elevation of Hct suggests dehydration and need for fluid replacement.
Platelet function and coagulation factors are altered as a result of CPB and don’t normalize for up to 12 hours after surgery.
Body temperature is also lowered for open heart surgery, which can depress normal platelet function for a time, even after the client is rewarmed, raising the risk of abnormal bleeding (Sorensen et al, 2006).
Imbalances—hyperkalemia or hypokalemia, hypernatremia or hyponatremia, and hypocalcemia—can affect cardiac function and fluid balance.
Verifies oxygenation status, effectiveness of respiratory function, and acid-base balance.
Provides good evidence of the filtering function of the kidneys and a measure of the degree of systemic hydration.
Fluctuations may occur because of preoperative nutritional status, presence of organ dysfunction, and impact of IV infusions.
Elevated in the presence of acute, recent, or perioperative myocardial infarction (MI).
Reveals heart size and position, pulmonary vasculature, and changes indicative of pulmonary complications, such as at- electasis or pulmonary edema. Verifies condition of valve prosthesis and sternal wires, position of pacing leads, intravas- cular or cardiac lines.
Identifies changes in electrical and mechanical function such as might occur in immediate postoperative phase, acute or peri- operative MI, valve dysfunction, and pericarditis.