1 Timby/Smith: Introductory Medical-Surgical Nursing, 11/eChapter 29: Caring for Clients Undergoing Cardiovascular Surgery
2 Cardiac Surgical ProceduresCardiopulmonary bypass (extracorporeal circulation) Mechanically circulating and oxygenating blood outside of the body while the beating heart is stopped Disadvantages: long operative period, anticoagulation, hypotension, risk for stroke, dysrhythmia
3 Myocardial RevascularizationCoronary Artery Bypass Indications Client has multiple coronary artery occlusions. Atheromas are calcified and noncompressible. Anatomic location of the occlusion interferes with the safe insertion of a coronary artery catheter.
4 Myocardial Revascularization—(cont.)Coronary Artery Bypass—(cont.) Procedure Bypassing or detouring around the occluded portion of one or more coronary arteries with a relocated blood vessel Graft vessel: saphenous vein Alternate graft vessel: internal mammary, internal thoracic arteries, basilic, cephalic vein in arm, radial artery, gastroepiploic artery from stomach
5 Myocardial Revascularization—(cont.)Surgical Techniques Conventional Coronary Artery Bypass Graft (CABG) Procedure: attach harvested saphenous vein to aorta or below the occlusion Types: double, triple, or quadruple
6 Myocardial Revascularization—(cont.)Surgical Techniques—(cont.) Off-Pump Coronary Artery Bypass (OPCAB) No use of cardiopulmonary bypass machine; adenosine (Adenocard) used to slow heart rate Instruments lift and stabilize graft vessels on anterior, lateral, and posterior wall of beating heart. Advantage: reduced mortality rate, fewer postoperative complications, decreased postoperative recovery time
7 Myocardial Revascularization—(cont.)Surgical Techniques— (cont.) Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) Procedure: endoscopic view of heart and grafting vessels through small incision between the ribs Limitations: only one or two vessels grafting
8 Myocardial Revascularization—(cont.)Port access coronary artery bypass (PACAB) Also called TECAB Procedure: uses cardiopulmonary bypass machine attached to femoral artery and vein rather than great vessels of heart Triple lumen vascular catheter inserted via thoracoscope; video camera and transesophageal echocardiography to visualize operative area Advantage: shortened operative period, reduced mortality rate from complications, faster recovery
9 Question A client is recovering from a conventional coronary artery bypass graft (CABG) procedure. The nurse can expect the following: A) Assess a 12-inch midchest incision. B) Anticipate a 3- to 4-day hospitalization. C) A shorter recovery period due to no use of the cardiopulmonary bypass machine D) Minimum of one to two grafted arteries
10 Answer A) Assess a 12-inch midchest incision. Rationale: A conventional CABG includes 12-inch midchest incision and duration of hospitalization of 7 to 10 days and 6- to 10-week recovery time. The minimum number of grafted arteries is five. The use of a cardiopulmonary bypass is used during the CABG.
11 Valve Repairs and ReplacementsMethods of repair Commissurotomy: opening adhesions in the valve cusps; thoracotomy Balloon valvuloplasty: balloon catheter to stretch the stenosed valve Cardiopulmonary bypass Valvuloplasty: valve repair Annuloplasty: repair of fibrous ring that encircles the valve
12 Valve Repairs and Replacements—(cont.)Valve replacements Types Mechanical valve Bioprosthetic valve Advantages: less surgical trauma, decreased blood loss, faster mobility, less mechanical ventilation, improved cosmetic appearance
13 Repair of Ventricular Aneurysm and Heart TumorsCauses: infarcted area of myocardium balloons outward and form thrombi; myocardial infarction (MI) Emergency procedure to suture weakened area Removal of heart tumors Benign and malignant tumors—rare Benign tumors extend from pedicle—uncomplicated; malignant tumors—poor prognosis
14 Repair of Heart Trauma Nonpenetrating injury of the chest—results in cardiac tamponade Causes: crushing injury causing bruising and bleeding Treatment: bed rest, pericardiocentesis, open thoracotomy Penetrating injury Causes: stab wound Treatment: large tears—surgery; causes immediate shock from hemorrhage
15 Heart TransplantationCauses: cardiomyopathy, end-stage coronary artery disease, end-stage heart failure, congenital cardiac defects National Organ Transplant Act (1984) Transplant problems—(cont.) Rejection—hyperacute, acute or chronic rejection; fever, flulike symptoms, shortness of breath, chest pain, weight gain, fatigue, elevated blood pressure Immunosuppressive drugs: cyclosporine (Sandimmune), azathioprine (Imuran)
16 Heart Transplantation—(cont.)Transplant problems—(cont.) Infection Causes: bacterial, viral, and fungal infections due to immunosuppressive drugs; symptoms similar to rejection Life threatening; treated with antibiotics, antivirals, antifungals High cost—preheart transplant evaluation, surgery, drugs, postsurgery care, and follow-up tests—million dollars
17 Heart Transplantation—(cont.)Transplant problems—(cont.) Cardiovascular disease—CAD common problem among heart transplant recipients; do not experience angina because heart’s nerve supply is not intact Rate of survival: 85% to 90% 1 year after surgery, 10-year survival 56% Scarcity of donor organs—20% of 3000 people awaiting heart transplant die before donor becomes available
18 Question Clients awaiting heart transplantation are assigned a status code that corresponds to their medical urgency. The nurse understands that if a client is determined a Status 1B, the client must have the following qualifications: A) The client is considered temporarily unsuitable to receive a thoracic organ transplant. B) The client requires mechanical circulatory support. C) The client requires continuous mechanical ventilation. D) The client has a left or right implanted ventricular assist device.
19 Answer D) The client has a left or right implanted ventricular assist device. Rationale: A client with a Status 1B must have at least one of the following devices or therapies: left or right ventricular assist device or continuous infusion of intravenous inotropes.
20 Central or Peripheral Vascular Surgical ProceduresVascular grafts—bypass or replace diseased sections of major systemic blood vessels; aorta, femoral, popliteal artery Types Synthetic fiber: Dacron, Teflon Human tissue: cadavers
21 Central or Peripheral Vascular Surgical Procedures—(cont.)Embolectomy and thrombectomy: removal of thrombus or embolus occluding a major vessel Replacement graft Endarterectomy Procedure: resection and removal of lining of an artery Removes atherosclerotic plaques from aorta, carotid, femoral, or popliteal arteries
22 Nursing Management for Client Undergoing Cardiovascular SurgeryHemodynamic monitoring—assess the volume and pressure of blood in heart and vascular system; surgically inserted catheter Methods BP monitoring: catheter placement in peripheral artery; radial, brachial or femoral artery CVP: right atrial pressure; normal 2 to 7 mm Hg; jugular or subclavian vein Pulmonary artery pressure monitoring: assess left ventricular function; pulmonary capillary wedge pressure, left ventricular end-diastolic pressure, cardiac index
23 Nursing Care Plan: Cardiac or Vascular SurgeryNursing Diagnosis: Knowledge Deficit Assess client’s and family’s knowledge concerning procedures. Nursing Diagnosis: Anxiety Demonstrate competence when performing skills. Administer anxiolytics as orders. Nursing Diagnosis: Risk for Impaired Gas Exchange Assess lung sounds, LOC, and ABG results. Administer oxygen; inspect chest tubes frequently.
24 Question A client recovering from cardiovascular surgery is at risk for decreased cardiac output related to impaired ventricular contraction. To maintain an adequate cardiac output, nursing interventions include: A) Elevating head of bed as much as possible B) Administering prescribed inotropic and antidysrhythmic medications C) Assessing sternal or leg incisions for redness D) Encouraging leg exercises every hour while awake
25 Answer B) Administering prescribed inotropic and antidysrhythmic medications Rationale: Inotropic medications increase the force of heart contraction, and antidysrhythmic medications promote normal conduction, depolarization, and repolarization of myocardial tissue to ensure normal cardiac output.