18 Cardiac surgery
Overview/pathophysiology
Surgical intervention may be necessary to treat acquired or congenital heart disease. Coronary artery bypass grafting (CABG) is done to treat blocked coronary arteries. A portion of the saphenous vein, internal mammary artery, gastroepiploic artery, or radial artery is excised and anastomosed to coronary arteries, thereby revascularizing the affected myocardium. Valve repair or replacement, another type of cardiac surgery, is performed for patients with valvular stenosis or valvular incompetence of the mitral, tricuspid, pulmonary, or aortic valve. Some patients may require replacement of the aortic arch and aortic valve because of an aortic aneurysm. Cardiac surgery is also performed to correct heart defects that are either acquired or congenital, such as ventricular aneurysm, ventricular or atrial septal defects, transposition of the great vessels, and tetralogy of Fallot. Heart transplantation may be considered for some patients diagnosed with end-stage cardiac disease; however, the national shortage of acceptable donor organs remains a problem. Many patients waiting for heart transplants will undergo surgery to receive a ventricular assist device, which will serve as a bridge to transplant. Combined heart-lung transplantation is performed for patients with end-stage disease affecting both organs. Immunosuppressive treatment to prevent organ rejection after heart transplantation is similar to that of patients who receive a renal transplant. See “Care of the Renal Transplant Recipient,” p. 216.
Health care setting
Nursing diagnosis for preoperative patients:
Deficient knowledge
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess patient’s health care literacy (language, reading, comprehension). Assess culture and culturally specific information needs. | This assessment helps ensure that information is selected and presented in a manner that is culturally and educationally appropriate. |
| Assess patient’s level of knowledge about the diagnosis and surgical procedure, and provide information as necessary. Encourage questions, and allow time for verbalization of concerns and fears. | Level of knowledge will vary from patient to patient. Some patients find detailed explanations helpful; others prefer brief and simple explanations. The amount of information given depends on the patient’s learning needs and should be individualized. |
| When appropriate, provide orientation to the ICU and equipment that will be used postoperatively. | Patient’s familiarity with the unit and equipment optimally will promote understanding and minimize stress. |
| Provide instructions for and demonstrate deep breathing and coughing; ask patient to give a return demonstration. | Deep breathing and coughing are essential postoperative techniques that reinflate the lungs after heart-lung bypass and help prevent atelectasis and pneumonia. |
| Reassure patient that postoperative pain may be managed with medication. Explain the types of medication administration available, i.e., epidural, patient-controlled analgesia (PCA), intermittent intravenous (IV), and per os (PO). | This information may aid in reducing anxiety about postoperative pain and increase understanding of types of pain medication. |
| Advise patient that in the immediate postoperative period, speaking will be impossible but that other means of communication (e.g., nodding, writing) will be available. | An endotracheal tube that will assist with breathing will prevent speech. Knowledge that alternative methods will be employed will reassure patient and prepare him or her for their use. |
| Review and demonstrate sternal precautions with patient. | Sternal precautions include how to get in and out of bed and chair without using upper extremities; not lifting, pushing, or pulling more than 5-10 lb with each upper extremity for a period of 4-6 wk; and not driving a car for the same period of time. |
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