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Continuity of Care in Cardiac Surgery
CONTINUITY OF CARE IN CARDIAC SURGERY Marcus L. Walker, R.N., and Patricia
E. Kasmarik, R.N.
Because open heart surgery has become an acceptable form of therapy for cardiac abnormalities and certain diseases of the heart, it has become necessary for nurses to gain more extensive knowledge of this form of therapy and a clear conception of their role in its implementation. Patients undergoing cardiac surgery pass through three phases during their period of hospitalization: the pre-operative phase, the operative phase and the post-operative/ recovery phase. Progression and continuity of the nursing management of cardiac surgery patients is a necessity. This paper will attempt to provide guidelines for integrating the phases with the planning of nursing care. Hopefully, that care will represent a cohesive, continuous physiological and psychological experience for the patient. Although many procedures are used in such
Marcus L. Walker, R.N., M.A., is a graduate of Teachers College, Columbia University, New York, N. Y. Formerly, Instructor-in-Charge,Medical Surgical Nursing 11, Mount Sinai Hospital School of Nursing, New York City, Mr. Walker is presently Assistant Professor of Nursing, Cornell University New York Hospital School of Nursing. Patricia E. Kasmarik, R.N., B.S.N., is a graduate of Bellevue Hospital School of Nursing and Hunter College, New York, N. Y. Miss Kasmarik is presently Assistant Instructor, Medical Surgical Nursing 111, Mt. Sinai Hospital School of Nursing, New York, N. Y.
62
operations, the transposition of great vessels, valve replacements, commissurotomies and different arrhythmias, the nursing care involved in these procedures has many common factors. The cardiac patient has probably lived with his abnormality for many years, adjusting his activities so that they are compatible with his handicap and his life needs. His family has also made certain adjustments. In some instances, he may enter the hospital somewhat frightened and apprehensive. Because of this, he should be admitted to a semi-private room in which the other patient is not infected. His placement in a single room or a room with another patient who has undergone surgery tends to increase his apprehension and should be avoided. Prior to the actual hospitalization of this patient, some preparations should be initiated after an evaluation of his charts and diagnostic reports. Such preparation may include cardiac catheterization and angiographic studies, while remaining tests can usually be done at the bedside or in the laboratory without discomfort to the patient. These include:
1. Hemoglobin, Hematocrit, Red Blood Cell Count, White Blood Cell Count, Reticulocyte Count, Platelet Count, bleeding and clotting times.
AORN Journal
2. Routine Urinalysis. 3. Blood Urea Nitrogen, Blood Sugar, Prothrombin time, Serum protein with A/G Ratio, Serum electrolytes Sodium, Calcium, Potassium and Chlorides. 4. Weight and Height on admission, then weight daily before breakfast. 5. Electrocardiograms, Phonocardiograms and vectorcardiograms. 6. Blood type and.cross match. Another facet of preparation for cardiac surgery consists of acquainting the patient with the members of the staff who are going to care for him. In some hospitals, the nurses take the patient on a tour of the Recovery Room Suite and the Cardiac Intensive Care Unit where he will be during his immediate postoperative hospitalization. In other institutions, the nurses visit the patient to explain the set-up as well as the rationale and policies of the unit. At this time, they can also take the opportunity to make observations of the patient’s physical and psychological states. In addition to the nurse’s visit, resident physicians and an anesthesiologist usually visit the patient. The anesthesiologist can evaluate the patient’s state of anxiety and establish his pre-operative medication requirements, while also ruling out or allaying any patient misconceptions regarding anesthesia. The patient may be visited by a member of the clergy at his own request or at the request of a member of his family. It is the responsibility of the nurse to be familiar with the availability of the service and to provide privacy when such services are requested.
Spiritual needs should be met in whatever way seems most desirable to the patient. For many patients, there is a close relationship between emotional well-being and religion.
PRE-OPERATIVE PREPARATION Preparation of the patient on the evening prior to surgery consists of an extensive shave prep. The shave area includes an area from the neck to the knees, side to side, including axilla and arms, (brachial cannulations) pubis and perineum. To diminish the chances of postoperative infection, the shave is followed with a phisohex bath. The nurse should check the pre-operative shave for thoroughness and adequacy. The importance of proper skin preparation cannot be overemphasized. The area to be prepped must always be considerably larger than the contemplated incision, because in cardiac surgery further unexpected extension of the incision may be necessary. Prophylactic antibiotics are administered the evening and morning preceding surgery. Procaine penicillin 600,000 units and streptomycin 0.5 Gm. are frequently used. Appropriate substitutions are made if ,thereis an allergy to penicillin or streptomycin. Blood balance techniques must be meticulous to afford replacement of an amount equal to that lost during surgery. In the operating room, the patient is weighed pre-operatively and again post-operatively with a metabolic scale. In order to keep the venous return to the heart at optimum, it is not an uncommon procedure to replace additional blood.
EXAMPLES OF NURSING CARE PLANS NEEDS
O.R. NURSING APPROACH
Environment Free From Contamination.
Create and maintain sterile field by using appropriate gowning and gloving techniques, setting up instruments supplies and equipment to be used in case. Make sure members of operating room team carry out appropriate aseptic techniques. The circulating
February 1969
RATIONALE All articles used in the operation have been sterilized previously. Microorganisms are everywhere, and if the sterile area or field is to remain so all persons and articles must be handled a p propriately. Contact with unsterile objects contaminates a
63
NEEDS
Safety and Comfort in O.R.
Psychological 1. Freedom from Anxiety 2. Acceptance
I. Patent airway and adequate ventilation
O.R. NURSING APPROACH
RATIONALE
nurse and the scrub nurse work as a team to create and maintain the sterile field, eliminating all unnecessary tra6ic into the room. During the c a s e k e e p all personnel not required for proper course of the case out of the room. The number of observers restricted.
sterile object. There is a contamination factor which is even more serious with the open heart surgical patient.
Assists in the moves of the patient from cart to O.R. table. Assists the Anesthesiologist. Places knee strap. Assists Anesthesiologist Attention to physical aspects of caTe prior to anesthesia induction. Keep patient covered avoiding over exposure. Observe vital signs Keep record of urinary output via urometer during the operation. During the operation the nurse assists in the control of hemorrhage. The scrub nurse anticipates the needs of the surgeon by observing the field of operation very carefully. The nurse is responsible for the total coordination of the room.
Unconscious patients require close observation and protection. The patient should be in as comfortable position as possible awake or asleep. Circulation must not be impeded. Respiration must be unobstructed. There should be no undue pressure-nerves require protection.
Be aware of the various meanings of surgery that the patient may have being performed. Integrated psychological and physiological preparation of the patient is achieved in a teaching plan. Know the three fears most often seen with the surgical patient: 1. Fear of the unknown 2. Fear of poor prognosis 3. Fear of death or disability. Develop appreciation for the beliefs and convictions of the patient.
The reactions seen in patients undergoing major surgery are dependent on their attitudes and knowledge about it.
P.O. NURSING APPROACH If a cufled “tracheostomy tube” ( nasoendotracheal, oral endotra-
cheal) tube is in place, deep endotracheal suctioning-inflate-deflate-reinflate cuff (suctioning each time) irrigate the trachea with 5 . 1 0 ~ ~normal saline and Ambu while cuff is inflated.
64
Hemorrhage may cause shock, excessive blood l o s s d e a t h . Time is of utmost importance in open heart surgery or any surgery. The more rapidly and efficiently the surgical team can work, the less time the patient has to be anesthetized. Emergency equipment should be available and in operating condition.
The control of anxiety depends on a knowledge of these fears.
Spiritual advisors can allay anxiety for many patients.
Deflation of tracheostomy tube cuff needed routinely (ql-2H) to prevent necrosis to the wall of the trachea. Loosen secretions, expand the lung to capacity which is not achieved by the continuous uniform pressure of the respirator.
AORN Journal
NEEDS
P.O.NURSING APPROACH
RATIONALE
If 0, is warranted-humidity is a must. Positive pressure hreathing machine is frequently used. If not intuhated, an 0, tent with humidity is used. Second day-IPPB q lh-2h x 15 min. Encourage deep hreathing and coughing, turn and position q2h. Usually semi-Fowler’s position, check vital signs and color. Note expansion of lungs by inspection and aeration by auscultation with a stethoscope. Check patency of chest tubes, check X-ray results for lung findings. 11. Maintenance of Cardiac OutPut
111. Nutrition
and Hydration, Electrolyte Balance, Blood Replacement
IV. Prevention of Infection
V. Decrease Gastric Distention
February 1969
1. Electronic monitoring apparatus attached to patient. 2. V/S and temperature monitored. 3. Check patency of arterial and venous lines for accurate pressure readings. 4. Check patient’s color, skin temperature and quality of respirations. 5. Chest tubes to underwater seal d r a i n a g w h e c k for air leak. 6. Clamps a t bedside for use if seal is broken. 7. Milk the chest tubes. 8. Check quantity and character of chest drainage. 9. Check urine output via Foley catheter hourly and note specific gravity.
Observation of developing arrhythmias and cardiac functioning. V/S changes are indicative of hemorrhage, respiratory distress, temperature elevation in. creases metabolism and cardiac work load.
1. Maintenance of I.V. functioning at designated rate. Note any infiltration and take a p propriate action, chart intake and output accurately. 2. Check for signs of electrolyte imhalance-note lab reports. 3. Check chest tube drainagequality and quantity-blood replacement as indicated.
KCI is given to maintain a needed amount of cardiac muscle irritability.
1. Administer Procaine Penicillin 600,000 U. q 12 h, Streptomycin 0.5 Gram q 12 h.
Airborne contaminant during surgery and postoperatively. Predisposition to infection kept in check.
1. Naaogastric tube to gravity drainage. 2. Irrigation of tube as needed.
Gastric distention increases from swallowing excessive amounts of air and secretions. It will put increased pressure on the diaphragm causing respiratory distress.
Removal of fluid and air from the pleural space, allowing reexpansion of the lungs.
A decreased output would he related to renal ischemia, which is caused by a decrease in cardiac output.
Nutrition and hydration for replacement of lost fluid from chest, urine, insensible perspiration, nasogastric drainage.
65
NEEDS
P.O. NURSING APPROACH
RATIONALE
VI. Relief of Pain and Restlessness.
1. Morphine Sulfate q 3h PRN (dosage dependent on individual) 1. Foley catheter to urimeter. 2. Hourly recording of urine output and specific gravity. 3. Bowel movements are not common for the first two days. Good hygiene, bed bath, special mouth care since patient is NPO. (Procedure adjusted if orally intubated) Brush teeth, mouth wash and glycerine and lemon swabs. Positioning-encourage patient movement while in bed.
Allows for rest and tolerance for procedures (deep breathing, coughing, etc.) An indication of renal function. I t can be a tool in guiding the fluid intake and in avoiding pulmonary edema.
VII. Elimination
VIII. Skin and Mouth Care
.
IX. Activity X. Safety
XI. Psychological Support
Assist patient in movement. Check that tubes are securely attached. Keep only essential equipment at the bedside. 1. Encourage verbalixation by patient. 2. Talk with patient, while caring for him. 3. Explain all procedures at level of patient’s comprehension. 4. Emphasize the progress the patient is making. 5. Explanation to relatives. 6. To provide privacy for the patient.
POST-OPERATIVE MANAGEMENT After surgery, the patient will return directly to the Cardiac Recovery Room or Cardiac Intensive Care Unit. He will be fitted with a nasotracheal, endotracheal or tracheostomy tube which will require attachment to a respirator. A nasogastric tube is also in place and draining by gravity. He will have several intravenous infusions running, two of which will be the arterial and central venous lines used for pressure readings to determine cardiac output. Chest dressings and chest tubes are also present. The tubes drain the mediastinal and lateral pleural spaces and can be placed on
66
.
Promote circulation for a bed patient and prevent skin breakdown. Oral hygiene to prevent drying, cracking lips and promote comfort. Prevent hypostatic pneumonia, promote circulation, prevent contractures. Prevent unneeded delay in the recovery phase of illness.
Reassurance and encouragement tend to reduce apprehension and anxiety.
If relatives have some understanding, they will communicate less anxiety to the patient while visiting with him. There are male and female patients in the same area as well as visitors. Prevents embarrassment on part of patient.
opposite sides of the patient. A t all times,they are to remain connected to water-sealed drainage. An indwelling Foley catheter is usually inserted, and the patient attached to an electrocardiographic monitor. These procedures are utilized to allow observation of urinary output and to monitor the electrical impulses from the heart. Post-operative temperatures were not specifically mentioned in the nursing care plan because temperature elevation is not a common complication to all patients following this type of surgery. In the presence of such an eleva-
AORN Journal
tion, however, an oxygen tent or tepid sponge baths may be employed to cool the patient. A hypothermia blanket or mattress may also be helpful. Pulmonary status may be checked by auscultation X-rays. Deep endotracheal suctioning is done to remove excessive secretions from the nasopharyns, trachea, and bronchial tree which might obstruct the airway and interfere with respiration. GENERAL CONSIDERATIONS The arterial catheter is removed on the first post-operative day, and the patient is permitted to come out of the oxygen tent for short intervals on the first and second postoperative days. The rectal temperatures continue to be taken with a thermistor until the patient is ambulatory. After the lung is fully re-expanded, and all drainage has stopped, the intercostal catheter is removed on or about the third post-operative day. The patient is then gradually and progressively ambulated, first to and into a chair, and then later, in taking a few steps with the assistance of the nurse. During this period he is observed closely; any reactions that would indicate problems are noted and reported immediately.
If the patient has had his heart electively arrested in the operating room, as is done in some cases when an artificial valve is inserted or when a ventricular septa1 defect is repaired, ambulation will be slower. The heart may have been temporarily weakened by the procedure. The ultimate decision about the patient’s readiness to progress to ambulation, of course, rests with the attending and resident Medical Staff. As a general rule, however, the patient is usually out of bed on the third or fourth post-operative day. Cutdowns and chest tubes are removed by this time. By the fifth to seventh post-operative day, the patient is then ready for transfer from the Cardiac Intensive Care area to his regular nursing unit in the hospital.
February 1969
CARE OF THE PATIENT ON HIS RETURN TO THE GENERAL NURSING UNIT Even though he is ambulatory and progressing well, the patient will continue to need very close observation and careful management. The nurse must continue to encourage him to move about, cough frequently, breath deeply, and continue moderate exercises of his extremities. He should not, however, become exhausted or overtired, and the nurse must be alert to signs of overexertion. The Medical Staff controls the physical activities of the patient, but the Nursing Staff must use good judgment in implementing the details of the medical plan. Antibiotics and cardiac medications are continued and any diet modifications or restrictions are carried out as ordered. Sutures are usually removed between the seventh and ninth post-operative days. In children, the seventh day usually shows the wound to be well-healed, and in some instances, sutures are removed at this time. Special situations may arise when prosthetic valves have been used. Some patients require post-operative anticoagulant therapy which is specifically ordered as the need arises. In some patients who have undergone cardiac surgery, delayed emotional reactions also occur. Individuals who may have appeared placid and stoic may become highly excitable, demonstrating erratic behavior on or about the seventh post-operative day. The underlying causes for this delayed-reaction behavior are not fully understood, but it is common to patients who have hidden their fears very carefully from the medical and nursing personnel in the early stages of their hospitalization. Emotional problems like these should be treated as they occur in an empathic and understanding manner, for fear may be due to ignorance, false knowledge, or to a true knowledge of the facts. Occasionally, a disturbed patient may require psychiatric consultation. Thus, the nurse should be alert to signs of erratic behavior and report them.
67
SUMMARY Open heart surgery has become an acceptable form of therapy for patients with cardiac problems. The professional nurse must be able to understand her role and be able to function effectively in caring for the patient undergoing cardiac surgery. The major component in this nursing care is continuity in the three phases. The need for alert and careful obser-
vation in order to recognize symptoms necessitating action to prevent complications which might be disastrous for the patient cannot be overemphasized. The patient cannot be comfortable and at rest unless both his body and mind are at ease. The nurse must be aware of the possibility of emotional problems following cardiac surgery and take appropriate steps toward their solution.
REFERENCES Alexander, Edythe, et al., Care of the Patient in Surgery Including Techniques, 4th Edition, The C. V. Mosby Company, St. Louis, 1967. Fordham, Mary E., Cardiovascular Surgical Nursing,
MacMillan Company, - . New York, 1962. Hurst, J. Willis and Logue, R. Bruce, Eds., The Heart, McGraw-Hill Book Company, New York, 1966.
HEART TRANSPLANT GUIDELINES The House of Delegates of the A M A adopted jive guidelines regarding heart transplantation: 1 ) The right o f the prospective donor to the best possible medical care must remain sacred. The cause of death must be evident, and the fact of death must be established and demonstrated by adequate, current and scientific evidence observed by no less than two physicians not associated with the surgical transplant team. 2) The evolution of therapy must be orderly, and a registry should be established to allow an exchange of transplant information among investigators.
3) Transplantation should be restricted to patients f o r whom there is no other means of therapy oflering a life-sustaining prognosis. 4 ) A law such as the Uniform Anatomical Gift Act should be adopted to facilitate the donation of organs, to remove medicologal problems generated by conflicting state laws, and to insure the best possible donor-recipient matches.
5 ) The public must be made fully aware of the problems that accompany the introduction of a new means of treatment and the rationale for the protocol followed. THE A M A NEWS
68
AORN Journal
E. Kasmarik, R.N.
Because open heart surgery has become an acceptable form of therapy for cardiac abnormalities and certain diseases of the heart, it has become necessary for nurses to gain more extensive knowledge of this form of therapy and a clear conception of their role in its implementation. Patients undergoing cardiac surgery pass through three phases during their period of hospitalization: the pre-operative phase, the operative phase and the post-operative/ recovery phase. Progression and continuity of the nursing management of cardiac surgery patients is a necessity. This paper will attempt to provide guidelines for integrating the phases with the planning of nursing care. Hopefully, that care will represent a cohesive, continuous physiological and psychological experience for the patient. Although many procedures are used in such
Marcus L. Walker, R.N., M.A., is a graduate of Teachers College, Columbia University, New York, N. Y. Formerly, Instructor-in-Charge,Medical Surgical Nursing 11, Mount Sinai Hospital School of Nursing, New York City, Mr. Walker is presently Assistant Professor of Nursing, Cornell University New York Hospital School of Nursing. Patricia E. Kasmarik, R.N., B.S.N., is a graduate of Bellevue Hospital School of Nursing and Hunter College, New York, N. Y. Miss Kasmarik is presently Assistant Instructor, Medical Surgical Nursing 111, Mt. Sinai Hospital School of Nursing, New York, N. Y.
62
operations, the transposition of great vessels, valve replacements, commissurotomies and different arrhythmias, the nursing care involved in these procedures has many common factors. The cardiac patient has probably lived with his abnormality for many years, adjusting his activities so that they are compatible with his handicap and his life needs. His family has also made certain adjustments. In some instances, he may enter the hospital somewhat frightened and apprehensive. Because of this, he should be admitted to a semi-private room in which the other patient is not infected. His placement in a single room or a room with another patient who has undergone surgery tends to increase his apprehension and should be avoided. Prior to the actual hospitalization of this patient, some preparations should be initiated after an evaluation of his charts and diagnostic reports. Such preparation may include cardiac catheterization and angiographic studies, while remaining tests can usually be done at the bedside or in the laboratory without discomfort to the patient. These include:
1. Hemoglobin, Hematocrit, Red Blood Cell Count, White Blood Cell Count, Reticulocyte Count, Platelet Count, bleeding and clotting times.
AORN Journal
2. Routine Urinalysis. 3. Blood Urea Nitrogen, Blood Sugar, Prothrombin time, Serum protein with A/G Ratio, Serum electrolytes Sodium, Calcium, Potassium and Chlorides. 4. Weight and Height on admission, then weight daily before breakfast. 5. Electrocardiograms, Phonocardiograms and vectorcardiograms. 6. Blood type and.cross match. Another facet of preparation for cardiac surgery consists of acquainting the patient with the members of the staff who are going to care for him. In some hospitals, the nurses take the patient on a tour of the Recovery Room Suite and the Cardiac Intensive Care Unit where he will be during his immediate postoperative hospitalization. In other institutions, the nurses visit the patient to explain the set-up as well as the rationale and policies of the unit. At this time, they can also take the opportunity to make observations of the patient’s physical and psychological states. In addition to the nurse’s visit, resident physicians and an anesthesiologist usually visit the patient. The anesthesiologist can evaluate the patient’s state of anxiety and establish his pre-operative medication requirements, while also ruling out or allaying any patient misconceptions regarding anesthesia. The patient may be visited by a member of the clergy at his own request or at the request of a member of his family. It is the responsibility of the nurse to be familiar with the availability of the service and to provide privacy when such services are requested.
Spiritual needs should be met in whatever way seems most desirable to the patient. For many patients, there is a close relationship between emotional well-being and religion.
PRE-OPERATIVE PREPARATION Preparation of the patient on the evening prior to surgery consists of an extensive shave prep. The shave area includes an area from the neck to the knees, side to side, including axilla and arms, (brachial cannulations) pubis and perineum. To diminish the chances of postoperative infection, the shave is followed with a phisohex bath. The nurse should check the pre-operative shave for thoroughness and adequacy. The importance of proper skin preparation cannot be overemphasized. The area to be prepped must always be considerably larger than the contemplated incision, because in cardiac surgery further unexpected extension of the incision may be necessary. Prophylactic antibiotics are administered the evening and morning preceding surgery. Procaine penicillin 600,000 units and streptomycin 0.5 Gm. are frequently used. Appropriate substitutions are made if ,thereis an allergy to penicillin or streptomycin. Blood balance techniques must be meticulous to afford replacement of an amount equal to that lost during surgery. In the operating room, the patient is weighed pre-operatively and again post-operatively with a metabolic scale. In order to keep the venous return to the heart at optimum, it is not an uncommon procedure to replace additional blood.
EXAMPLES OF NURSING CARE PLANS NEEDS
O.R. NURSING APPROACH
Environment Free From Contamination.
Create and maintain sterile field by using appropriate gowning and gloving techniques, setting up instruments supplies and equipment to be used in case. Make sure members of operating room team carry out appropriate aseptic techniques. The circulating
February 1969
RATIONALE All articles used in the operation have been sterilized previously. Microorganisms are everywhere, and if the sterile area or field is to remain so all persons and articles must be handled a p propriately. Contact with unsterile objects contaminates a
63
NEEDS
Safety and Comfort in O.R.
Psychological 1. Freedom from Anxiety 2. Acceptance
I. Patent airway and adequate ventilation
O.R. NURSING APPROACH
RATIONALE
nurse and the scrub nurse work as a team to create and maintain the sterile field, eliminating all unnecessary tra6ic into the room. During the c a s e k e e p all personnel not required for proper course of the case out of the room. The number of observers restricted.
sterile object. There is a contamination factor which is even more serious with the open heart surgical patient.
Assists in the moves of the patient from cart to O.R. table. Assists the Anesthesiologist. Places knee strap. Assists Anesthesiologist Attention to physical aspects of caTe prior to anesthesia induction. Keep patient covered avoiding over exposure. Observe vital signs Keep record of urinary output via urometer during the operation. During the operation the nurse assists in the control of hemorrhage. The scrub nurse anticipates the needs of the surgeon by observing the field of operation very carefully. The nurse is responsible for the total coordination of the room.
Unconscious patients require close observation and protection. The patient should be in as comfortable position as possible awake or asleep. Circulation must not be impeded. Respiration must be unobstructed. There should be no undue pressure-nerves require protection.
Be aware of the various meanings of surgery that the patient may have being performed. Integrated psychological and physiological preparation of the patient is achieved in a teaching plan. Know the three fears most often seen with the surgical patient: 1. Fear of the unknown 2. Fear of poor prognosis 3. Fear of death or disability. Develop appreciation for the beliefs and convictions of the patient.
The reactions seen in patients undergoing major surgery are dependent on their attitudes and knowledge about it.
P.O. NURSING APPROACH If a cufled “tracheostomy tube” ( nasoendotracheal, oral endotra-
cheal) tube is in place, deep endotracheal suctioning-inflate-deflate-reinflate cuff (suctioning each time) irrigate the trachea with 5 . 1 0 ~ ~normal saline and Ambu while cuff is inflated.
64
Hemorrhage may cause shock, excessive blood l o s s d e a t h . Time is of utmost importance in open heart surgery or any surgery. The more rapidly and efficiently the surgical team can work, the less time the patient has to be anesthetized. Emergency equipment should be available and in operating condition.
The control of anxiety depends on a knowledge of these fears.
Spiritual advisors can allay anxiety for many patients.
Deflation of tracheostomy tube cuff needed routinely (ql-2H) to prevent necrosis to the wall of the trachea. Loosen secretions, expand the lung to capacity which is not achieved by the continuous uniform pressure of the respirator.
AORN Journal
NEEDS
P.O.NURSING APPROACH
RATIONALE
If 0, is warranted-humidity is a must. Positive pressure hreathing machine is frequently used. If not intuhated, an 0, tent with humidity is used. Second day-IPPB q lh-2h x 15 min. Encourage deep hreathing and coughing, turn and position q2h. Usually semi-Fowler’s position, check vital signs and color. Note expansion of lungs by inspection and aeration by auscultation with a stethoscope. Check patency of chest tubes, check X-ray results for lung findings. 11. Maintenance of Cardiac OutPut
111. Nutrition
and Hydration, Electrolyte Balance, Blood Replacement
IV. Prevention of Infection
V. Decrease Gastric Distention
February 1969
1. Electronic monitoring apparatus attached to patient. 2. V/S and temperature monitored. 3. Check patency of arterial and venous lines for accurate pressure readings. 4. Check patient’s color, skin temperature and quality of respirations. 5. Chest tubes to underwater seal d r a i n a g w h e c k for air leak. 6. Clamps a t bedside for use if seal is broken. 7. Milk the chest tubes. 8. Check quantity and character of chest drainage. 9. Check urine output via Foley catheter hourly and note specific gravity.
Observation of developing arrhythmias and cardiac functioning. V/S changes are indicative of hemorrhage, respiratory distress, temperature elevation in. creases metabolism and cardiac work load.
1. Maintenance of I.V. functioning at designated rate. Note any infiltration and take a p propriate action, chart intake and output accurately. 2. Check for signs of electrolyte imhalance-note lab reports. 3. Check chest tube drainagequality and quantity-blood replacement as indicated.
KCI is given to maintain a needed amount of cardiac muscle irritability.
1. Administer Procaine Penicillin 600,000 U. q 12 h, Streptomycin 0.5 Gram q 12 h.
Airborne contaminant during surgery and postoperatively. Predisposition to infection kept in check.
1. Naaogastric tube to gravity drainage. 2. Irrigation of tube as needed.
Gastric distention increases from swallowing excessive amounts of air and secretions. It will put increased pressure on the diaphragm causing respiratory distress.
Removal of fluid and air from the pleural space, allowing reexpansion of the lungs.
A decreased output would he related to renal ischemia, which is caused by a decrease in cardiac output.
Nutrition and hydration for replacement of lost fluid from chest, urine, insensible perspiration, nasogastric drainage.
65
NEEDS
P.O. NURSING APPROACH
RATIONALE
VI. Relief of Pain and Restlessness.
1. Morphine Sulfate q 3h PRN (dosage dependent on individual) 1. Foley catheter to urimeter. 2. Hourly recording of urine output and specific gravity. 3. Bowel movements are not common for the first two days. Good hygiene, bed bath, special mouth care since patient is NPO. (Procedure adjusted if orally intubated) Brush teeth, mouth wash and glycerine and lemon swabs. Positioning-encourage patient movement while in bed.
Allows for rest and tolerance for procedures (deep breathing, coughing, etc.) An indication of renal function. I t can be a tool in guiding the fluid intake and in avoiding pulmonary edema.
VII. Elimination
VIII. Skin and Mouth Care
.
IX. Activity X. Safety
XI. Psychological Support
Assist patient in movement. Check that tubes are securely attached. Keep only essential equipment at the bedside. 1. Encourage verbalixation by patient. 2. Talk with patient, while caring for him. 3. Explain all procedures at level of patient’s comprehension. 4. Emphasize the progress the patient is making. 5. Explanation to relatives. 6. To provide privacy for the patient.
POST-OPERATIVE MANAGEMENT After surgery, the patient will return directly to the Cardiac Recovery Room or Cardiac Intensive Care Unit. He will be fitted with a nasotracheal, endotracheal or tracheostomy tube which will require attachment to a respirator. A nasogastric tube is also in place and draining by gravity. He will have several intravenous infusions running, two of which will be the arterial and central venous lines used for pressure readings to determine cardiac output. Chest dressings and chest tubes are also present. The tubes drain the mediastinal and lateral pleural spaces and can be placed on
66
.
Promote circulation for a bed patient and prevent skin breakdown. Oral hygiene to prevent drying, cracking lips and promote comfort. Prevent hypostatic pneumonia, promote circulation, prevent contractures. Prevent unneeded delay in the recovery phase of illness.
Reassurance and encouragement tend to reduce apprehension and anxiety.
If relatives have some understanding, they will communicate less anxiety to the patient while visiting with him. There are male and female patients in the same area as well as visitors. Prevents embarrassment on part of patient.
opposite sides of the patient. A t all times,they are to remain connected to water-sealed drainage. An indwelling Foley catheter is usually inserted, and the patient attached to an electrocardiographic monitor. These procedures are utilized to allow observation of urinary output and to monitor the electrical impulses from the heart. Post-operative temperatures were not specifically mentioned in the nursing care plan because temperature elevation is not a common complication to all patients following this type of surgery. In the presence of such an eleva-
AORN Journal
tion, however, an oxygen tent or tepid sponge baths may be employed to cool the patient. A hypothermia blanket or mattress may also be helpful. Pulmonary status may be checked by auscultation X-rays. Deep endotracheal suctioning is done to remove excessive secretions from the nasopharyns, trachea, and bronchial tree which might obstruct the airway and interfere with respiration. GENERAL CONSIDERATIONS The arterial catheter is removed on the first post-operative day, and the patient is permitted to come out of the oxygen tent for short intervals on the first and second postoperative days. The rectal temperatures continue to be taken with a thermistor until the patient is ambulatory. After the lung is fully re-expanded, and all drainage has stopped, the intercostal catheter is removed on or about the third post-operative day. The patient is then gradually and progressively ambulated, first to and into a chair, and then later, in taking a few steps with the assistance of the nurse. During this period he is observed closely; any reactions that would indicate problems are noted and reported immediately.
If the patient has had his heart electively arrested in the operating room, as is done in some cases when an artificial valve is inserted or when a ventricular septa1 defect is repaired, ambulation will be slower. The heart may have been temporarily weakened by the procedure. The ultimate decision about the patient’s readiness to progress to ambulation, of course, rests with the attending and resident Medical Staff. As a general rule, however, the patient is usually out of bed on the third or fourth post-operative day. Cutdowns and chest tubes are removed by this time. By the fifth to seventh post-operative day, the patient is then ready for transfer from the Cardiac Intensive Care area to his regular nursing unit in the hospital.
February 1969
CARE OF THE PATIENT ON HIS RETURN TO THE GENERAL NURSING UNIT Even though he is ambulatory and progressing well, the patient will continue to need very close observation and careful management. The nurse must continue to encourage him to move about, cough frequently, breath deeply, and continue moderate exercises of his extremities. He should not, however, become exhausted or overtired, and the nurse must be alert to signs of overexertion. The Medical Staff controls the physical activities of the patient, but the Nursing Staff must use good judgment in implementing the details of the medical plan. Antibiotics and cardiac medications are continued and any diet modifications or restrictions are carried out as ordered. Sutures are usually removed between the seventh and ninth post-operative days. In children, the seventh day usually shows the wound to be well-healed, and in some instances, sutures are removed at this time. Special situations may arise when prosthetic valves have been used. Some patients require post-operative anticoagulant therapy which is specifically ordered as the need arises. In some patients who have undergone cardiac surgery, delayed emotional reactions also occur. Individuals who may have appeared placid and stoic may become highly excitable, demonstrating erratic behavior on or about the seventh post-operative day. The underlying causes for this delayed-reaction behavior are not fully understood, but it is common to patients who have hidden their fears very carefully from the medical and nursing personnel in the early stages of their hospitalization. Emotional problems like these should be treated as they occur in an empathic and understanding manner, for fear may be due to ignorance, false knowledge, or to a true knowledge of the facts. Occasionally, a disturbed patient may require psychiatric consultation. Thus, the nurse should be alert to signs of erratic behavior and report them.
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SUMMARY Open heart surgery has become an acceptable form of therapy for patients with cardiac problems. The professional nurse must be able to understand her role and be able to function effectively in caring for the patient undergoing cardiac surgery. The major component in this nursing care is continuity in the three phases. The need for alert and careful obser-
vation in order to recognize symptoms necessitating action to prevent complications which might be disastrous for the patient cannot be overemphasized. The patient cannot be comfortable and at rest unless both his body and mind are at ease. The nurse must be aware of the possibility of emotional problems following cardiac surgery and take appropriate steps toward their solution.
REFERENCES Alexander, Edythe, et al., Care of the Patient in Surgery Including Techniques, 4th Edition, The C. V. Mosby Company, St. Louis, 1967. Fordham, Mary E., Cardiovascular Surgical Nursing,
MacMillan Company, - . New York, 1962. Hurst, J. Willis and Logue, R. Bruce, Eds., The Heart, McGraw-Hill Book Company, New York, 1966.
HEART TRANSPLANT GUIDELINES The House of Delegates of the A M A adopted jive guidelines regarding heart transplantation: 1 ) The right o f the prospective donor to the best possible medical care must remain sacred. The cause of death must be evident, and the fact of death must be established and demonstrated by adequate, current and scientific evidence observed by no less than two physicians not associated with the surgical transplant team. 2) The evolution of therapy must be orderly, and a registry should be established to allow an exchange of transplant information among investigators.
3) Transplantation should be restricted to patients f o r whom there is no other means of therapy oflering a life-sustaining prognosis. 4 ) A law such as the Uniform Anatomical Gift Act should be adopted to facilitate the donation of organs, to remove medicologal problems generated by conflicting state laws, and to insure the best possible donor-recipient matches.
5 ) The public must be made fully aware of the problems that accompany the introduction of a new means of treatment and the rationale for the protocol followed. THE A M A NEWS
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AORN Journal