Extended Recovery Timelines There is increasing pressure to send patients home as soon as possible after cardiac surgery. Most institutions have specific timelines or collaborative pathways that uncomplicated patients are expected to follow. Once patients transfer out of the intensive care unit (ICU) to an intermediate care unit, they are expected to move steadily toward discharge. Nurses need to be aware of what care individual patients need to move them toward these goals. Nurses are in a unique position to influence progress toward a speedy discharge. Objectives In this chapter, you will learn: 1. Goals patients need to achieve prior to discharge 2. Timelines for meeting goals for discharge GOALS FOR RECOVERY After cardiac surgery, most patients are transferred out of the ICU on postoperative day (POD) 1 or 2. The actual time of transfer depends on the time of day when surgery was completed and how quickly the patient was extubated and became hemodynamically stable. Patients who do not experience serious complications after surgery should approximately follow the timeline discussed below. Some patients are slower to progress along the expected recovery pathway. These include the very elderly and patients with preoperative comorbidities such as respiratory disease, diabetes, obesity, renal failure, myocardial infarction (MI), cardiac arrest, or cardiogenic shock. CARDIOVASCULAR One of the main goals after cardiac surgery is a stable cardiovascular status. The uncomplicated patient should be hemodynamically stable and weaned off vasoactive medications by POD 1. Once stable, the pulmonary artery catheter and any arterial lines may be discontinued. A central line should be left in place while the patient is receiving intravenous (IV) medications that may damage peripheral vessels. In patients for whom a central line is no longer needed, a peripheral IV line should be placed prior to removal of the central line. IV access should be maintained until discharge. FAST FACTS in a NUTSHELL Invasive monitoring catheters and central lines should be removed as soon as possible to prevent catheter related bloodstream infection. Once transferred to intermediate care, cardiac surgery patients should be monitored using telemetry, because they are at very high risk of arrhythmias during the period after surgery. Once transferred, vital signs should be monitored every 4 to 8 hours until discharge. Medications Aspirin should be started 6 to 8 hours postoperatively. If the patient is unable to take aspirin orally, aspirin should be given via nasogastric (NG) tube, or as a suppository. Aspirin should be held in patients with a platelet count less than 100,000 mm3. A beta-blocker should be started as soon as the patient is hemodynamically stable and the blood pressure and heart rate will tolerate it (typically systolic blood pressure over 90–100 mmHg and heart rate greater than 50–55 beats per minute). Serum potassium should be kept at or above 4 to 5 mg/dL and serum magnesium at or above 2 mg/dL. Epicardial Wires Once a patient’s rhythm is stable and a pacemaker is no longer needed, epicardial pacing wires should be electrically isolated and taped to the patient’s chest. Care should be taken not to touch the end of these wires with bare hands. Static electrical energy could be transmitted down the wire directly to the patient’s heart. Wires should be taped in place so they are not inadvertently pulled out. When not in use, epicardial pacing wires should be electrically isolated to prevent electrical shock to the heart. However, wires should be easily and quickly accessible in case pacing is emergently required. Epicardial pacing wires should be removed on POD 4 or 5 if not being used to pace the patient and if the patient’s rhythm has been stable for at least 24 hours. Epicardial pacing wires must be removed prior to discharge. These wires may be removed by a physician or other specially trained health care provider. They are usually removed by pulling straight out and applying pressure to the insertion site. Patients should be on bed rest for 1 hour after epicardial wire removal and should be monitored for signs of cardiac tamponade for several hours after removal. RESPIRATORY Patients should be weaned from the ventilator and extubated within 4 to 12 hours after surgery. Once extubated, patients usually require low-flow oxygen for a few days. Oxygen saturation should be kept greater than 92%. Oxygen should be weaned off prior to discharge unless the patient was oxygen dependent prior to surgery. Patients should use an incentive spirometer every hour while awake. This is critical for resolution of postoperative atelectasis. They should also be encouraged to cough to clear any respiratory secretions. Patients will need to splint the midline sternotomy incision by wrapping their arms around a pillow and holding it tightly to their chest while coughing. This stabilizes the incision and decreases pain involved in coughing and taking deep breaths. Coughing, deep breathing, and incentive spirometry are all important for lung expansion and improving postoperative atelectasis. FLUID STATUS Immediately after surgery, intake and output should be measured every hour. Urine output should be kept greater than 0.5 mL/kg/hr. Weight should be monitored daily and compared with preoperative weight. Edema and fluid retention after cardiac surgery are common. Diuretics, especially furosemide (Lasix), are often used to help rid the body of excess fluid. Edema hampers healing of incisions and the goal is to return patients to their preoperative weight. Diuretics are commonly used to decrease edema and help patients return to their preoperative weight. This is important for wound healing. WOUNDS AND DRAINS Assessing surgical wounds and drains is important for preventing and catching early signs and symptoms of infection. Prophylactic antibiotics are given just before surgery (within an hour of cut time) and continued for 24 to 48 hours. Unless there is an indication of infection, antibiotics should not be given for more than 48 hours after surgery. Signs and symptoms of infection include redness at the incision site, incisional pain or tenderness (especially if pain is worsening), drainage from the incision, and fever or malaise. Drains Patients typically come out of the operating room with a urinary catheter and one or more chest tubes. To reduce the risk of a catheter-related urinary tract infection, the urinary catheter should be removed no later than POD 2 unless there is an appropriate indication to leave it in place. According to the Centers for Disease Control, in its campaign to reduce hospital-acquired infections, a urinary catheter may be left in place after POD 2: • If the patient has acute urinary retention or bladder outlet obstruction • If there is a need for accurate measures of urinary output in critically ill patients • If there is a need to assist in healing of open sacral or perineal wounds in incontinent patients • If the patient requires prolonged immobilization • To improve comfort for end of life care if needed
NURSING IMPLICATIONS: Nurses play an important role in making sure invasive lines are removed when no longer needed. If no orders exist to remove the pulmonary artery catheter or arterial line or to place a peripheral IV and discontinue the central line, orders should be obtained from the physician.
NURSING IMPLICATIONS: Administration of medications per physician order is critical in cardiac surgery patients to prevent complications. Aspirin is given to improve graft patency and prevent thromboembolism from implanted valves after surgery. Beta-blockers reduce the incidence of perioperative MI and may help prevent atrial fibrillation and other arrhythmias. Maintaining serum potassium and magnesium at ordered levels is important for prevention of arrhythmias.
FAST FACTS in a NUTSHELL
NURSING IMPLICATIONS: Epicardial pacing wires must be managed appropriately to avoid complications. They must be electrically isolated and taped to avoid accidental dislodgement. After removal, patients must be monitored for signs and symptoms of cardiac tamponade. (See Chapter 10 for more information on cardiac tamponade.)
NURSING IMPLICATIONS: Patients need to be educated and encouraged to cough, deep breathe, and use an incentive spirometer every hour. Family members should be educated and enlisted, whenever possible, to assist in reminding patients to perform these important respiratory exercises. Patients and families should be taught that these exercises and ambulation are the two most important things they can do to speed recovery and reduce complications.
FAST FACTS in a NUTSHELL
FAST FACTS in a NUTSHELL
NURSING IMPLICATIONS: Patients should be educated on the signs and symptoms of infection. They will need to know this information upon discharge. They also need to know what to report to the nurse or physician while in the hospital.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
