Preparing a Patient for Cardiac Surgery

The urgency of cardiac surgery determines how much time is available to prepare the patient. Patients preparing for elective surgery have the most time available. Patients who undergo emergency surgery are often taken directly to the operating room and have little or no preparation for surgery. Preparation time for patients who require urgent surgery varies from several hours to several days. In any of these cases, effort should be made to complete as many of the steps for preparing the patient as time allows. Patients who are fully prepared for surgery have the fewest complications and recover the quickest.

Objectives

In this chapter, you will learn:

1. What tests and exams should be completed for patients prior to cardiac surgery

2. How patient and family education can prevent complications after surgery

3. What medications should be given prior to and on the day of surgery

FAST FACTS in a NUTSHELL

Patients who undergo urgent or emergent surgery are at highest risk of post-op complications.

PRE-OP EXAMINATION

Patients who will undergo cardiac surgery need to have a health history taken and a baseline physical exam performed. The health history should include questions about chronic health conditions and prior surgeries. Any history of depression or other psychosocial problems should be noted. Heart and lung sounds should be documented. Neurological status should be assessed. Many patients experience alterations in neurological status after cardiac surgery and an accurate pre-op baseline is important for determining changes. Blood pressure should be taken in both arms. Significant differences in blood pressure between arms can signify subclavian stenosis, which may mean the internal mammary artery cannot be used as a bypass conduit. Smoking history should be documented. Patients who have smoked in the past 6 months are at higher risk for pulmonary complications.

NURSING IMPLICATIONS: A thorough pre-op history and exam are important to determine which patients are at higher risk for complications. They are also critical if post-op issues arise and a baseline is needed for comparison.

FAST FACTS in a NUTSHELL

Factors that increase post-op mortality and morbidity include respiratory or airway disease, diabetes, obesity, renal failure or dialysis, previous cardiac surgery, low left ventricular ejection fraction, and advanced age (older than 80 years).

Laboratory Tests

A number of laboratory tests should be completed, including a complete blood count, renal and liver function tests, electrolytes, coagulation panel, and arterial blood gases. A urinalysis is usually completed and often a thyroid panel is drawn. These tests give important information about the patient’s risk for complications. Patients with renal or liver disease may need adjustments made to dosages of certain medications. Any infection should be treated prior to surgery whenever possible. Patients with bleeding disorders often require increased use of blood products during and after surgery. Electrolyte abnormalities should be corrected prior to surgery to reduce the risk of arrhythmias. Patients with subclinical hypothyroidism, which occurs without overt symptoms, are more likely to have coronary artery disease. These patients are also more likely to develop certain complications after surgery, such as atrial fibrillation, heart failure, and gastrointestinal complications (Hillis et al., 2011)

NURSING IMPLICATIONS: Pre-op laboratory data are critical to determine patients at risk for complications. For example, patients with pre-op renal insufficiency are at much higher risk of developing renal failure after surgery and a urinalysis may uncover a urinary tract infection that needs to be treated prior to surgery.

Other Diagnostic Tests

A 12-lead electrocardiogram (ECG) should be performed on patients who will undergo cardiac surgery. This provides a baseline for comparison post-op. Patients at high risk of carotid stenosis should undergo a carotid ultrasound prior to cardiac surgery. High-risk attributes include age of more than 65 years, left main coronary stenosis, peripheral arterial disease, history of transient ischemic attack or stroke, hypertension, smoking, and diabetes (Hillis et al., 2011). Severe carotid stenosis, which can be diagnosed by ultrasound, puts patients at high risk of a stroke during cardiac surgery. If severe carotid stenosis is discovered, this should be treated either by carotid endarterectomy or by carotid stenting prior to surgery. Some centers perform carotid endarterectomy in the cardiac operating room immediately before cardiac surgery. (See Chapter 14 for more detailed discussion of stroke.)

PATIENT AND FAMILY EDUCATION

Pre-op education should include what will happen during surgery. It is especially important for patients to be aware of what it will be like when they awaken from surgery as this decreases anxiety. It is also important for the patient’s family to understand the amount and types of medical devices used in the intensive care unit (ICU). If allowed and time permits, patients and family members should be given a tour of the ICU. It is also important to teach patients and family the length of the usual stay in the ICU and what to expect during that time. Patients may be surprised to learn that they may be asked to get out of bed into a chair as early as the morning after surgery.

Pre-op teaching should also include presence of chest tubes and epicardial wires, early ambulation, need for pain medication, use of an incentive spirometer or other deep breathing exercises, and incision care. This helps mentally prepare the patient and family for post-op recovery.

NURSING IMPLICATIONS: Educating patients and families about what to expect after surgery is an important nursing function. Nurses working in pre-op areas should familiarize themselves with the practices of their own institution so that accurate information is given and questions can be answered.