Page 619 - Cardiac Nursing

6/3
0/2
6/3
0
0
0/2
1
7:4
1
009
009
0
5-6
22.
5-6
59
59
22.
xd
xd
q
q
q
A
p
A
95
A
p
ara
ara
t
p
t
95
Pa
Pa
5
7:4
5
Pa
e 5
e 5
g
g
g
K34
0-c
25_
p
LWB K34 0-c 25_ p pp595-622.qxd 06/30/2009 17:45 Page 595 Aptara
LWB
LWBK340-c25_
C CHAPTER
CHAPTER
HAPTER
C C C C Cardiac Surgery
a
r
a
y
r
y
y
e
d
d
g
S
Denise Ledoux* / Helen Luikart †
os
in
in
nt
pi
nt
b
s
f
to
rg
st
i
ay
he
ic
o
s
ve
ul
d
al
er
io
b
ma
n
nt
Su Surgical intervention continues to bee a mainstay of treatment for r en enters thee hospittal. Prior to cardiac surgery, the patient shhould
i
a
l
t
ys
ph
acquired heart disease even though catheter-based interventional ha havve a complete physical exxamiinnation with special aattention
e
al
ic
n
c
ia
p
m
te
as
io
t
cu
ve
h
is
A
n
cardiology techniques have continued to expand a dnd medical gi givenn to the cardiovvascullar examinationn. A new history and
mi
e
ti
na
ic
ys
al
ph
,
ch
ma na ge me nt h i ve T hi ch ap te fo cu se s on s ur gi ca in physical examination, chest radiograph, electrocardiogram
n
management haas improvedd. Thiss chapterr focuses on surgicall in-
g
le
ly
ro
ct
et
e
bl
pl
er
um
e
te
a
terventions for acquired heart disease, including coronary artery (ECG), complete blood count, serum electrolytes, coaggulatiion
AB
ni
G)
bypass grafting ((CABG), i imally invasive cardiac surgery, screen, and typing and crossmatching of blood are performed.
mi
ll
transmyocardial revascularization, cardiomyoplasty, aortic surgery, Preoperative anemia increases the risk of postoperative adverse
2
and cardiac transplantation. Surgical intervention for valvular events. These data provide information about other disease
heart disease is briefly discussed in this chapter and is more ex- conditions and cardiac problems. Patients are admitted to the
tensively covered in Chapter 29. hospital early on the morning of their surgery. Patients with
symptomatic carotid bruits should undergo carotid duplex to as-
sess for carotid stenosis. Patients with pre-existing cerebrovascu-
EVOLVING TRENDS IN CARDIAC lar disease are at increased risk for neurological complications
SURGERY postoperative. Patients with chronic lung disease should un-
3
dergo pulmonary function testing and arterial blood gas testing
Cardiac surgical operative techniques continue to evolve. Arterial because they may have difficulty weaning from the ventilator.
bypass conduits such as the internal mammary artery (IMA) are Patients undergoing valve surgery should complete a dental eval-
the preferred graft because of excellent long-term patency. Addi- uation and work before valve repair or replacement to reduce the
tional arterial conduits have expanded to include radial artery chance of dental disease being a source of bacteremia and possi-
grafts and the gastroepiploic artery (GEA). Spawned by laparo- ble prosthetic valve endocarditis. Patients are maintained on an-
scopic approaches in other surgical subspecialties, minimally inva- tianginal, antihypertensives, and heart failure medications until
sive cardiac surgery (with and without cardiopulmonary bypass surgery. Antiplatelet medications are usually discontinued before
[CPB]) has rapidly developed. Computer-assisted, robotic CABG, surgery: aspirin, clopidogrel, and nonsteroidal anti-inflamma-
and mitral valve surgical procedures have been preformed world tory agents should be stopped before surgery to prevent periop-
1
wide on highly selected patients. Shorter intubation times and erative bleeding. The Society of Thoracic Surgeon’s workforce
“rapid recovery” programs have led to shorter intensive care unit recommends that for elective patients and for high-risk aspirin-
stays with overall reduced length of stay and decreased cost asso- sensitive patients that aspirin should be stopped 3 to 5 days
4
ciated with cardiac surgery. before surgery. Patients on warfarin usually have their dose
As cardiac surgery techniques evolve, the population changes withheld 3 to 5 days preoperatively. Patients on warfarin for pre-
as well. Interventional cardiology approaches such as coronary an- vious mechanical valve replacements may be admitted 1 to
gioplasty, atherectomy, and stenting have delayed or replaced sur- 2 days before surgery for intravenous heparin. Heparin is with-
gical revascularization in patients with coronary lesions amenable held 1 to 2 hours before surgery, whereas enoxaparin is usually
5
to catheter-based interventions. stopped 12 hours beforehand. In a study by Jones et al., pa-
tients on preoperative enoxaparin demonstrated a higher rate of
bleeding requiring re-exploration for bleeding (7.9% versus
PREOPERATIVE ASSESSMENT 3.7% in the unfractionated heparin group, P 0.03).
AND PREPARATION The preoperative nursing assessment should be thorough and
well documented because it provides baseline data for postopera-
tive comparison. The history should include a social assessment of
Before referral for cardiac surgery, patients complete their car-
diac work-up, which includes cardiac catheterization to define family roles and support systems, and a description of the patient’s
coronary artery anatomy and target vessels for revascularization; usual functional level and typical activities. Elderly patients or
stress testing to verify areas of ischemia; nuclear scans to identify those with limited social and emotional support may need addi-
areas of myocardial viability and ventricular function; and tional assistance from social service for effective discharge and re-
echocardiography to delineate valvular lesions, ventricular func- habilitation planning. The patient with acute coronary heart dis-
tion, and focal wall-motion abnormalities. Usually, most of the ease (CHD) may be hospitalized for only hours or days before
preoperative medical evaluation is completed before the patient surgery. A myocardial infarction may have occurred, or the patient
may be experiencing unstable angina. In either case, if CABG sur-
gery is being considered, then a cardiac catheterization must be
define
o
cor
if
indicated
to
determine
i
y
surger
s
formed
and
to
per
performed to determine if surgery is indicated and to define coro-
*Author of the section on cardiac surgery.
*A th r f th ti n n r d i r r
†
Author of the section on cardiac transplantation. nary anatomy.
595