UNIT 3 NURSING MANAGEMENT OF

PATIENTS WITH CARDIAC

SURGERY
Structure
3.0 Objectives
3.1 Introduction
3.2 Types of Cardiac Surgery
3.2.1 Extra Cardiac Surgery
3.2.2 Closed Heart Surgery
3.2.3 Open Heart Surgery
3.3 Principles of Cardiopulmonary Bypass Mechanism (CPB)
3.4 Pre-operative Nursing Management of Cardiac Surgical Patients
3.4.1 Early Pre-operative Care
3.4.2 Preparation on the Previous Day of Operation
3.4.3 Preparation on the Morning of Surgery
3.5 Post-operative Care of Patients
3.5.1 Respiratory Care on Admission (First two hours)
3.5.2 Cardiac Care on Admission (First two hours)
3.6 Rehabilitation of Cardiac Surgical Patients
3.7 LetUs SumUp
3.8 Key Words
3.9 Answers to Check Your Progress

3.0 OBJECTIVES
1
After studying this unit, you should be able to:
explain different types of Cardiac Surgeries;

) discribe the CPB and nursing management;

apply the knowledge and skills in giving preparative and postoperative
1
nursing care to patients for cardiac surgery; and
I

I educate the patient about early rehablitation.

3.1 INTRODUCTION -

In Unit 2, you have learned about the cardiovascular system and their
management with drug and other therapeutic regimes. There are many
conditions, which need further intensive interventions such as surgery, The first
cardiac surgery was structuring of a cardiac wound done in 1897. Then there was
a gradual progress in cardiac surgicai intervention like a PDA ligation, excision
of a coarcted segment of aorta and the Blalock-Taussing Shunt. After the
introduction of cardiopulmonary bypass in 1953, modifications and technical
i .
improvements in operative room and peri-operative patient care have abounded.
Respiratory and Many cardiac surgical interventions have become routine procedures. The nurse
Cardiovascular Nursing
who cares for these patients has been challenged to keep pace with rapid
technologic advances in cardiac surgical patient care. Patients of all ages, infants,
children, adult and old age, and patient with progressive diseases undergo cardiac
surgery. Nurse needs to advance her knowledge and competency to be an
effective team member in the cardiac surgical team.
In this Unit you will read about various cardiac surgical interventions and the
nursing management of such patients. You need to read more, participate in
discussions and care for patients undergoing cardiac surgery to keep yourself
updated with the latest developments, since development is very fast in this field.

3.2 TYPES OF CARDIAC SURGERY

Cardiac surgeries may be grouped into three types:

3.2.1 Extra Cardiac Surgery

Operation performed on the main vessels outside the heart or on the surface of
the heart.
Common Surgery Indication
Ligation of patient ductus arteries PDA .

Resection of the coarcted segment of aorta and Coarctation of aorta.

End-to-end anastomosis. Aortic aneurism.
Resection of aneurysm and grafting Chronic constrictive

Pericardectomy pericarditis.
Shunt Surgeries
Shunt is made between major arteries and veins to allow more blood to flow to
pulmonary artery for oxygenation.
i) Blalock-Taussig's Shunt: Tetrology of fallots
A shunt is done from the subclavian Tricuspid atresia
artery to the left pulmonary artery.
ii) Waterson Shunt:
Shunt from ascending arota to pulmonary artery.
iii) Pot's shunt: Tricuspid atresia.
Shunt from descending arota to pulmonary artery.
iv) Glenn Shunt
Shunt between superior vena cava and
Right pulmonary artery.
Pulmonary artery banding done to protect Trunkus arteriosis.
the pulmonary vasculature and to
decrease pulmonary pressure
Pericardictomy Chronic constrictive
pericarditis.
 Nursing Management of Patient
3.2.2 Closed Heart Surgery with Cardiac Surgery

Blind operations and access is obtained into the heart through incision on the
ventricular or atrial wall.

Commonest closed heart surgery done is mitral valvotomy. After exposing the
heart through a thoracotomy, a finger is inserted into the left atrium through a
small incision in the auricular appendage and a Tubb's dilator is inserted into the
left ventricle through a small incision in the left ventricular apex. Finger in the
left atrium guides the tip of the dilator into the valve orifice and the fused cusps
are separated by opening the dilator. .

These days, the dilation of the stenosed valve is possible with a special balloon
catheter (Balloon Valvuloplasty) which is done in the cardiac cath lab. This can
avoid a thoracotomy and longer stay in the hospital. But the cost of balloon
technique is very high and CMV is comparatively cheaper. Most people cannot
afford for the balloon technique.

3.2.3 Open Heart Surgery

These surgeries are done under alternative arrangements to continue oxygenated
systemic blood supply, while the heart is operated on (Cardiopillmonary bypass).
Common open heart surgeries are:
Open mitral valvotomy or commissurotomy. Mitral stenosis
Removal of thrombi from atrium and its appendage
Commissure incision, separation of fused chordae
Splitting of underlying papillary muscle, and debriding
the valve of calcium.
Annuloplasty Reconstruction of the valve leaflets Mitral regurgitation
and the annulus
With or without the aid of prosthetic rings Tricuspid regurgitation.
(carpentier ring).

Valve Replacement
Replacement of the diseased valve is done. This is done biologic tissue valves or
mechanical valves. Three types of biologic tissue valves are used.

Autografi : In this, tissues of the same persons is used to make a valve or

a valve itself is used e.g. pulmonary valve of a patient is
taken and placed on the diseased aortic valve and the valve
structure prepared from the pericardium is placed as
pulmonary valve. (Ross procedure)
Allografl : A valve taken from a dead human after processing is used for
replacing the diseased valve of another human being (tissue of
one species used for another of the same species).
Xenograft : Valves taken from pig or pericardial tissue of calves after
processing (porcupine and bovine valves).

Advantages of Tissue Valves

Need for anticoagulation therapy is only for a short duration in xenograft and
only there is rare need for anticoagulation therapy in autograft and allograft
tissues. Thrombogenicity is low in biologic tissue valves. The cost of the valve is
low.
Respiratory and Disadvantages
Cardiovascular Nursing
Tendency for early calcification and tissue degeneration is high and durability is
limited. Biological valves may be preferred in patients who cannot take
anticoagulant therapy e.g. women of child-bearing age. Age below 18 years and
very old person (after 70 years).
Mechanical Valves
They are made of a combination of metal alloys, pyrolite carbon and dacron.
Types of ilrlechanical Valves
Caged-ball Valve A metal cage with several stmts mounted in a circular
(Star-Edwards) ring, holiow metal or plastic ball inside cage. Durability
is high, but possibility of blood clots forming on or
around the valve with the risk of embolism is high.
Tilting Disc Valve Mobile lens shaped disc attached to a circular sewing
(Bjork-Shiley ring by two offset transverse struts. This has high
Medtronic Hall) durability and efficiency.
Bileaflet Valve Two pivoting semi-circular discs that open centrally,
mounted
(St. Jude) Directly onto a sewing ring.

Advantuges

Durability of these vales are long lasting.

Disadvantages

Need for anticoagulant therapy is life long.

Risk of thrombo-embolism is high.

Other associated problems included are para-valvular leak and endocarditis.

Valve replacement may be single valve replacement or double valve replacement

(MVR, DVR, MVR+ AVR)

Coronary artery bypass graft-coronary artery block.

Resection of thoracic aortic ai~eurysm-thoracic aortic aneurysm.

Excision of fibrous tissue or myxoma. Removal left atrial tumor.

Cardiom~~oplusty Cardiomyopathy

Cardiac transplantation End stage cardiac disease

(CMD)

The current technique is orthotopic technique. Refractory to medical therapy.

A large portion of the right and left atrium Cardiomyopathy specially

dilated

In the recipient is retained and the donor CMP is the nlnst co~mmon.

Heart is implanted to the atria

Operations to corrcct cortgenitaI a~zornu/ies Nursing Management of Patient
with Cardiac Surgery
Correction of congenital anomalies Most of them done in children.
Total correction TOF
Closure of septa1 defect ASD, VSD
Fountain operation Pulmonary artery stenosis
Blood from right atrium is directed to and
Pulmonary artery through a shunt. Tricuspid atresia.
Raskind procedure
(Atrial septostomy with a special balloon Transposition of Great
Catheter done in newborn as an Arteries (TGA)
Emergency intervention).
Later corrective surgeries done.
Corrective surget~ies

i) Atrial correction by Mustards operation. Atrium is opened and a baffle is

inserted into the atrial septum so that oxygenated blood from pulmanary
veins is directed to the right ventricle and then pumped into aorta. Systemic
venous blood is directed to left ventricle and pumped into pulmonap artery.

ii) Anatomic correction Arterial switch operation. Switching of aorta and

pulmonary artery to normal position.

Check Your Progress 1

1) Name
a) One extra cardiac surgery
........................................................................................................................
b) One closed heart surgery

c) One open-heart surgery

........................................................................................................................
2) Name one condition for the foliowing surgeries.
a) Rlalock-Taussig Shunt
........................................................................................................................
b) Glenn Shunt

c) Annuloplasty

d) Cardiomyoplasty
........................................................................................................................
Respiratory and
Cardiovascular Nursing 3.3 PRINCIPLES OF CARDIOPULMONARY
BYPASS MECHANISM (CPB)
What is CPB? It is a technique by which the mechanical function of the heart
and respiratory function of the lungs are replaced by a pump oxygenator that is
connected to the arterial and venous circulation of the patient.

Provide a bloodless field while the surgeon is enabled to operate on the

heart under direct vision and maintain homeostatis at the same time.

Principles
Function of heart and lung is taken over by a machine.
Protect the myocardium, while it is paralysed.
Prevent hemolysis and air or particular embolism.
Reduce the metabolic needs of the body.

Increase the renal perfusion.

Now we will see how these principles are taken care of while the surgeon is
provided a bloodless field and non-beating heart. There are specially trained
perfusionist who performs the CPB in cardiac operation theatre. Having a basic
understanding of the mechanism is important for nurses for the pre, peri and post
operative management of cardiac surgical patients.
The perfusionist assembles the circuit of the CPB. The air is expelled from the
tubing using isotonic saline. Then a priming solution is used for hemodilutin.
Hemodilution is a method of increasing the volume of blood plasma, which
results in reduced concentration of red blood cells. The shortage of donor bank
blood and high incidence of blood-borne diseases has led to the widespread use
of hernodilution for cardiopulmonary bypass. The patient's blood is collected in
specialized transfusion bags and reserved during surgery. Donated blood is added
to the circuit if needed.
Hemodilution
Advantages Disadvantages
Reduced use of donor blood. Hypokalemia

Decreased incidence of blood borne diseases Hypocalcemia

More efficient oxygenation Increase intracellular fluid.

Decreased viscosity of blood Excessive hemodilution

Reduced peripheral resistance Severe hypoxic acidosis

Improved urinary output Difficulty with oxygenation

Reduced platelet aggregation Low hematocrit

And embolisation .
1rnp;oved micro circulation
The amount of hemodilution ranges from 20 to 30 mVkg body weight resulting
in hematocrits that range from 18 per cent to 30 per cent. The excess water is
removed post- operatively with the aid of diuretics.
Hernoconcentration Nursing Management of Patient
with Cardiac Surgery
Before, during and after CPB, hemoconcentration allows the patient's blood to be
salvaged during surgery to help reduce the need for donor blood. Ultra filtration
during or after CPB allows for removal of plasma water. This preserves all blood
components allowing whole blood reinfusion. Centrifugation helps for reinfusion
of connectrated red blood cells.

Blood when allowed to flow out from body to the circuit tubings can get clotted.
To prevent this, heparinisation is done. Patient is administered 3 mg/kg body.
weight of heparin added before conilected to CPB. The activated clothing time is
brought to more than 400 sec, then connected to CPB. 1 mg/kg body weight of
heparin is added into the circuit every hour. ACT is monitored hourly.
Surgeon inserts cannulas into the right atrium via the superior and inferior vena
cavae (venous cannulation) and into the ascending aorta (arterial cannulation).
Aorta is cross-clamped.
Oxygenator Bubble oxygenators or membrane oxygenators are the commonly
used oxygenators. The venous blood mixed with priming solution passes into the
oxygenator where it is oxygenated and carbon dioxide is removed.
ITypotherrnia As the blood passes through the oxygenator, hypothermia machine
allows the blood to cool to the required temperature. Generally, the temperature
is brought down from 3 7 ' ~to 2 8 ' ~allowing the blood cool and then to circulate
through the body. Hypothermia reduces the body's demand for oxygen by
reducing the metabolic needs of body, specially brain. Local cooling of the heart
is further done by infusing the cold cardioplegic solution into the coronary
arteries or by using iced lactate locally.
Cardioplegia This is the technique employed during CPB to protect the
myocardium. This is achieved by infusing a specific amount of hypothemic
cardioplegic solution inixed with oxygenated blood into the coronary arteries.
The higher content of potassium in this solution causes a temporary cardiac
arrest and the surgeon performs the surgery on the non-beating heart. Ref. Fig.
3.1
Superior vena cava, , t lAscendina aorta

Fig. 3.1: Schematic drawing of cardiopinlmonary bypass system

Respiratory and 71ze pumps
Cardiovascular Nursing
The blood from the operating field is sucked with the help of the cardiotomy
sucker and pump, which is filtered to remove all particulate matter and then
passed to the oxygenator for oxygenation. The oxygenated blood is pumped into
the aorta via arterial filters where the particulate matter is filtered and air bubbles
escape into the atmosphere.
Cardioplegia is discontinued after the desired time.
After the cardiac surgery, the aortic cross clamp is released. As gradual re-
warming is done, the heart starts beating. Temperature is brought to 3 7 ' ~ .In
some cases, the surgeon may use direct internal defibrillation trying to revert the
fibrillating heart to sinus rhythm. After the heart starts beating, CPB is
discontinued after de-cannlation first aortic, then venous.
Neutvcrlizafio~zo f Heparin 11ij. Protamine Sulphate 1 mglkg body weight is
administere to the patient to neutralize the effect of heparin. ACT os brought to
normal. The patient is weaned off from CPB. The blood left in the circuit is
salvaged and transfused to the patient as plasma, packed cell or whatever is the
need. The patient's blood presetlied earlier is also transfused to the patient as per
the surgeon's decision according to the patient's condition.
:\fi>nitoringdone during the operation
Pressures-Mean arterial and venous pressures PA, P A W .
ECG
Ai-terial blood gases every 10 to 15 minutes.
Acid base balance.
Temperature-esophageal, rectal temperature recorded with probe.
Activated clotting 'ime.
Urine output.
Intra gastric drainage.
Serum electrolytes glucose.

Con7plication.s of CPB
Vital organ injuries may be caused by emboli, inadequate perfusion or abnormal
blood gases.
Myocardial damage.
Hypoxia, ischemic injury, emboli, surgical trauma.
Dysrhythmia.

Lungs Atlectasis.
Pleural effusion.

Kidneys Acute renal failure.

Acute tubular necrosis.

Gastrointesti~~al Segmental ischemia of small or large intestine.

Pancreatitis.
(3.1. bleeding.
Massive intestinal infarction.
4 CNS Cerebral oedema. Nursing Management of Patient
Embolism. . with Cardiac Surgery

Endocrine Increased blood glucose level.

Decreased production of insulin.
Haemorrhage
Hemolysis
Emboli
Psychosis
The patient is closely monitored during the operation by the team to identify and
take immediate corrective measures.
This is a very brief discussion of CPB. You need to discuss with the perfusionist
and other O.T. team member to understand more about the complex mechanism.

3.4 PRE-OPERATIVE NURSING MANGEMENT OF

CARDIAC SURGICAL PATIENTS
Cardiac surgical patients generally get investigated thoroughly before getting
referred to the surgeons. Many of them must have been on medical treatment for
Respiratory and some time. ECG, complete blood count, grouping, cross matching, serum
Cardiovascular Nursing electrolytes, glucose, urea, BLW, echocardiography, chest x-ray and cardiac
catheterization reports are available with the surgeon before the patient is
admitted for surgery. Doctors give a brief explanation about the. surgery the
patient requires, the risk involved, the cost of the surgery, average length of stay
for the patient in the hospital for surgery and the change in lifestyle to be
brought about after the surgery. The patients are given enough opporlunity to
clarify doubts. After all these and if the patient is willing, then the patient is
admitted to the ward for surgery. The nurse is the OPD also has a role in helping
the patient and family members to get to know the various activities related to
his surgery. Generally, the fdmily members are explained the need for blood
donation and made to donate 4-6 units of blood before patient's admission.
Patient is admitted two to three days prior to the day of surgery. Pre-operative
care can be discussed under three headings.

3.4.1 Early Pre-operative Care

Admission of patient-usual admission procedure to be completed.

Assessment of the patient.

IIistory
Physical examination
Emphasis on cardio respiratory system.
Assessment
Height, weight..
Records of previous illness, treatment.
Reports of diagnostic procedures.
Evaluation of patient's and family members' emotional status, coping
strategies.
Encourage for positive copying strategy.
Medication: Refer BNSL=106
Pre-operative Teaching
Brief explanation-anatomy, physiology of the cardio-respiratory system.
The disease and the operation which is going to be done.
Operation theatre.
Intensive care unit, about the various tubings and machines to which the
patient will be connected after the surgery. their purposes and duration.
Waiting roo111 and communication facilities for information about the
patient from time to time.
Take the patient to the ICU and introduce to the staff or the ICU nurse
visits the patient in the ward.
Demonstrating and making the patient to do return demonstration of all the
breathing exercises, pursed'lip breathing, abdominal breathing, hut'fing and
coughing. how to support the sternum while doing these exercises, range of
motion exercises. gradual ambulation and how to take steam inhalation.
 Encourage patient and significant others to come out with their doubts and Nursing Management of Patient
with Cardiac Surgery
give reply in simple language. Never give wrong assurance or information.
Explain the importance of prevention of infection and measures to be taken
e.g. cleanliness, hand washing, restricting visitors.
Collect all the investigation reports from OPD.
Anesthetist visits the patient to develop. a rapport to do pre-anesthetic check-
up and prescribe the pre-medication to be given to the.patient.
The surgeon/doctors explain about the surgery including the percentage of
I
risk and take a written informed consent from the patient or significant
I others. The informed consent form is signed by the doctor who explained
I

the risk and a witness.

3.4.2 Preparation on the Previous Day of Operation

Remove all the jewellery, nail polish, cut nails.
The patient's body is cleaned - shaving from chin to toe, including private
parts (whole body) expect in children is done for all open heart surgeries
and the trunk for closed heart surgery. After shaving, the patient is given a
thorough bath ~ncludinghair wash. Savlon is added to the water for bath
(Savlon bath). After the bath. the nurse inspects the patient's body to make
sure the preparation is done properly. After the bath, the patient is given a
sterile hospital dress to wear. The patient's bed is made with sterile sheet.
Instruct relatives not to sit on patient's bed.
Sensitivity test for the antibiotics is done and the results are recorded. Some
surgeons wish to start the antibiotic one day before the surgery.

Any investigations such as chest x-ray, CBC, blood sugar, urea, electrolyte,
ECG etc. is done and report collected.
A light meal is given early in the evening.

Instruct the patient not to take anything orally after 10 p.m. (fasting from 10
p.m.).
Administer the medication (anti-anxiety drugs) for a good sleep as
prescribed by the anesthetist. Assist the patient for a good sleep by providing
a comfortable environment.
Check and keep the case sheet with all records and reports and informed
consent form.

3.4.3 Preparation on the Morning of Surgery

Morning care
Hygiene Bowel and bladder emptying.

Ora'l hygiene, remove dentures if any, no lipstick.

Comb and make the hair into two plaits, cover the hair
with a triangular bandage.
Change the dress (with sterile dres( if needed.
Record the vital signs. i.e. TPR and BP
Administer the morning dose of antibiotics.
Respiratory and Apply two identification bands with name, age, sex, registration number,
Cardiovascular Nursing operation to be performed, pre-operative diagnosis, one on the left wrist and
the other on the chest part of the shirt.
Facilitate to meet the spiritual needs of the patient and family members.
Inform the patient and the significant others that the patient is going to be
pre medicated and after that not to disturb the patient and allow himher to
sleep.
Instruct the patient that sfhe is going to be pre medicated and helshe will
feel sleepy, not to get out of bed after pre-medication, empty bladder before
pre-medication. The patient will not be left alone when he is asleep, helshe
will be accompanied by the nurse to O.T. and will be handed over to the
O.T. team.
Administer the pre-medication as prescribed. Cardiac surgery patients are
generally pre-medicated with Inj. Morphine and Phenargan. Inj. Pethedme is
@rarelyused Inj. Atropine is not used. The nurse records the time, name,
dose, route of medication on the nurse's note and put her signature on the
nurse's note as well as on the anesthelist's instruction sheet. The pre-
medication is given one hour before surgery. The patient is made
comfortable and the side rails are placed up to prevent fall.
Accompany the patient to O.T. with complete case records of the patient and
hand over to the O.T. nurse. Significant family members are allowed to
come with the patient to the O.T. Reassure the patient and significant others.
 Nursing Management of Patient
3.5 POST-OPERATIW CARE OF PATIENTS with Cardiac Surgery

The first few days following cardiac operations are the most critical in terms of
the patient's survival. The safety with which a patient can be conducted through
this crisis period is largely dependent upon minute-to-minute observations and
interventions made by the cardiac nurse, who is really the first line of defense in
detecting and treating changes in the patient's condition. Good judgement must
be exercised in determining when to inform the attending physician of a change
in the patient's status or when the problem can be handled by the nurse at the

The patient's safety in this period also is dependent upon careful clinical and
laboratory observations, effective medical management, and avoidance of
predictable complications.
Let us briefly discuss about the post-operative management including the
predictable complications.

Caraiac surgical ICU is generally connected to the operation theatre so that the
patient can be wheeled into the ICU after surgery and also to wheel back the
patient to operation theatre in case of any post-operative complications such as
bleeding or cardiac tamponade.
Preparation of the Unit
Patient's unit is cleaned and carbolised thoroughly.
Special ICU bed and other equipments are als; carbolised.
Prepare the bed with sterile sheets.

Keep all the equipments at hand in working order.

Cardiac monitor with all the cables, ventilator with sterile water in
humidifier, central suction for endotracheal suction as well as low suction
system to connect the chest drainage system, arterial flush system with the
transducers set in order, drainage bottleshags for gastric drainage, central
oxygen supply for ventilator, IV Poleshangers, syringes, needles, emergency
drugs, emergency cart with sterile pack sets to meet any emergency,
defibrillator, pacemakers.

Keep ready the flow chadICU special charts (each hospital will have their
own cardiac surgery ICU charts). This chart is used to maintain the complete
records of activities and events in ICU. Hourly inputs of blood~plasma~other
colloids and crystalloids administered, hourly urine output, hourly chest
drainage in each drainage bottle, hourly gastric drainage, hourly monitoring
of arterial blood gas analysis, mean BP, pulse, heart rate, respiratory rate,
serum electrolyte, glucose, urea etc.and medication given and the nurse's
notes.
Immediate Post-operative Care'
The patient is accompanied to the ICU by a surgeon, anesthetist and the nurse
who assisted for the surgery with portable ventilator and ECG monitor. The
patient is shifted to the bed. The ECG leads are connected to the cardiac monitor.
The pressure lines-the CVP, ,LAP and arterial BP lines are connected to the flush
system via the transducer and then to monitor. Readings noted. The ventilator
connected to the ET tube after ET suction and the parameters are set and
Respiratory and assessed for effective working, chest drainages are connected to the central
Cardiovascular Nursing
suction and assessed for the patency of the chest tubes, milking of the tubes
done. Respiratory rate is assessed. Urinary bag is attached to bed, amount of
urine in the bag is r-neasured. Gastric drainage tube is unclarnped and the amount
of drainage noted. The temperature probe and pulse oxymetry leads are also
connected to the monitor. IV lines are assessed and volume of fluid in the
volume falsk is monitored and drip adjusted. The patient is made coi-nlbrtable
and reassured that the operation is over and is received h~mlherin ICU. (Refer
Fig. 3.2)

1. Nasogastric tube to
decompress stomach.
1
2. Endotrachzal tube for providing
mechanical ventilation, ventilatory
assistance, suctiunina and use 9
of end tidal C 0 2 mon'itor.
3. Swan Ganz catheter for monitoring
CVP, Pulmonary artery and
pulmonary afte wedge pressures,
temperature SV% , Can be used
for determining cadiac output, for
venous and pulmonary artery blood
samplina, and,for medication
adminis rat~onFlu~dintake is monitoi'ed.
4 ECG eltrodes for monttoring heart rate
and rhythm
5. SaO monitor for measuring arterial
oxy&n saturation.
6.Assess peripheral pulses: radial,
popliteal, posterior tib~al,dorsalis pedis
9
7. Epicardial pacing electrodes to
temporarily pace the heart.
8 Nled~astlnaland pleural chest tubes
attached to suction, drainage and wound
healing and monrtored
9. Radial arterial line with wrist armboard,
used for monitorin arterial blood
pressure and bloo! sampling.
6-
10. Indwelling catheter to closed drainage
system for accurate measurement
of urine output; a temperature probe
may be part of the indwelling catheter.

Respiratory Status - Chest movement; sounds, ventilator sett~ng( rate, tidalvolume, oxygen
concentrat'Inn\
Positive-er;d~~xpiratory
pressure (PEEP), etc.

Peripheral Vascular - ~ ~ &C.

~pulses,P coiour
UICJJIIIH,
, of~ skin,~ nail~beds,~lips,!earlobes, edema,
Renal function - Urinary output, specific gravity; osmoiarity, etc

Fluid and Intake; output from all drainage tubes, all cardiac output parameters,
~ l ~-
~status t and~the fol
~ owing
l (given
~ In box) indications of electrolyte imbalance.
~
Study this carefully and understand your role in observation and reporting

Hypokalemia : digitalis toxicity, dysrthythmias (U wave, AV Block, flat or inverted T waves)

Hyperkalemia : mental confusion, restlessness, nausea, weakness, paresthesias of
extremities, d srhthmias (tall, peaked T waves; increased amplitudes;
widening Q R complex:
~ prolonged QT interval)
Hyponatremia : weakness, fatigue, confusion, convulsions, coma
Hypocalcemia : paresthesias, carpel pedal spasm, muscle cramps, tetany
Hyprercalcemia : digitalis toxicity, asystole

Fig. 3.2: Post-operative care of the cardiac surgical patient

The immediate post-operative period for the patient who has undergone cardiac
surgery presents many challenges to the health team. All efforts are made to
facilitate the transition from the operating room to the intensive care unit with a
minimum of risk. Specific informatlon about the operation and inlportant factors
 about post-operative management are communicated by the surgical team and . Nursing klanagement of Patient
with Cardiac Surgery
anesthesia personal to the critical care nurse in the intensive care unit, who then
assumes responsibility for the patient's care. The patient's relatives are also
informed about the operation and condition of the patient in ICU.
The first few hours after surgery is very critical. After admitting the patient, the
flow chart recording is completed.

3.5.1 Respiratory Care on Admission (First two hours)

Patient is intubated and ventilator-dependent.

Monitor blood gases hourly and take corrective action immediately.

Hourly endotracheal suction with strict asepsis.
Asses breath sounds to document the placement of the endotracheal tube and
aeration of lungs bilaterally.
Continuously observe drainage form chest tubes. If the drainage is greater
than 70 mllhr form each individual tube and is wann, bright red and free-
flowing, haemorrhage is suspected. Do an immediate chest x-ray and view
the film to identify and complication.

Immediate Post-ope/-ative Perio J (24- 72houurs)

Monitor blood gases every hourly for the first 12 hours, then 2 hourly.

ET suction hourly, chest physiotherapy arid changing position of the patient

to promote ventilation and perfusion of the lungs. Four hourly chest x-ray
repeated. If no complication-breathing is effective and ABG is normal-the
patient is weaned off form ventilator gradually.

First-the patient is connected to "T" piece for two hours and ABG
monitored.

Through bronchial toileting done, cuff is released, encourage the patient to

take deep breath and while exhaling, the endotracheal tube is pulled out,
proper mouth wash is given.

I Humidified oxygen inhalation using a ventury mask, monitor ABG four

I
I hourly, cupping, clapping, vibrating and turning position as the cardiac statos
permits continued hourly.

I As the respiratory status shows satisfactory level, the patient is weaned off
I
form oxygen. Generally, in 48-72 hours, the patient is weaned off
completely form repiratory support. Coughing, hufting and other breathing
exercises every two hourly while awake. Support the strenal incision area
with a folded soft towel or small pillow while coughing and taking breathing
I exercises.
i
Steam inhalation given to assist to bring out the secretion.

Chest Dr~lrilzageTubes 124-72 h a ~ r s )

Continue milking of chest tube hourly.

i
! Monitor the amount, colour and record on the flow chart.
i
I Assess dressing for any soakage, any bulging and report immediately and
1 record.
Respiratory and X-ray chest.
Cardiovascular Nursing
When chest drainage is less than 50mV24hours, the chest tubes are removed.
The patient is explained about the procedure, an analgesic is administered,
encouraged to breath effectively, and the tube is pulled out, while the purse
stirng suture is tightened to prevent air entry into the chest. The wound is
properly sealed with adhesive and the patient is made comfortable. A chest
x-ray is done after 4 hours to assess the chest for lung expansion and any
collection of fluid.

a Encourage ambulation. (In some patients, the serous drainage may continue
to drain, then the patient is allowed to ambulate with the chest drainage
tubes and as the amount gets reduced, the tube is removed).

a Encourage breathing exercises and give chest physiotherapy and steam

inhalation.

3.5.2 Cardiac Care on Admission (First two hours)

ECG is monitored by more than one lead (three to five). Left atrial pressure,
arterial BP, central venous pressure, respiration rate, heart rate, body temperature
and pulse oxymetry is monitored continuously. Observation for any life
threatening dysrhythmia constantly done. Most of the patients will have
epicardial pacing leads from O.T. If there is need, the pacing wires are connected
to the external pacemaker and pacing as per the need is done.

Serum sodium and potassium is tested as soon as receiving the patient to ICU,
then every two hourly for 12 hours and then Q4H to Q6H. Hypokalemia and
hyperkalemia both can cause dysrhythmia. Keep defibrillator ready to use at the
bed side.

Administer the prescribed drugs-Many a time, the patients are put on

vasodilators such as sodium nitroprusside or nitroglycerine or sometimes on
dopamine or dobutamine 1V infusion as need basis.

Immediate Care (24- 72hottrs)

All monitoring and medications continued. Flushing of arterial lines are done at
regular intervals with heparin flush as well as whenever arterial blood is taken
for ABG. 12 lead ECG is recorded daily.

As the patient's condition stabilizes, with heart rate, pulse, respiration

temperature and arterial BP within normal limit, the patient is weaned off form
the pressure lines and vasodilators or vasopressor drugs. LA catheter, arterial
pressure line ad CVP to catheter are removed and pressure dressing applied to
the arterial puncture site and other dressing applied. Pacing wires kept in place.
Hb and hematocrit value monitored daily. Non-invasive pressure monitoring
done Q4H along other vital signs.

Fluid and Electorlytes

All fluid drained from the body is measured hourly and recorded. The colour
also is noted. Drainage form each chest tube is measured hourly and if there is
excess of chest drainage, specially bright red drainage, the patient is closely
monitored for haemorrhage. Blood replacement as per hourly status is done.
Many surgeon prefer to collect the drainage into an auto-transfusion set(within
six hours of operation) and is transferred to the patient in the form of packed
cell, platelet or plasma as per need.
IV fluid is infused using a volume flask and microchip set so that hourly needed Nursing Management of Patient
fluid is infused. Urine output is measured hourly. The colour(any hematuria) with Cardiac Surgery
specific grvity also in some cases are observed. In the initial hour (first 24
hours),urine output is more than normal due to hemodilution during surgery.
Diuretics are administered if urine output is less than 0.5 mllkgfhr (>3ml/hour).
See that the urinary catheter is not compressed gas. The colour and mount of
gastric drainage (if present) is noted hourly. Serum electrolytes are monitored
initially Q2FT and then Q4H for 24 hours and then twice a day. Supplement of
electrolytes or correction of hyperkalemia done. Blood urea nitrogen are serum
glucose is also done Q4H in the first 24 hours.

The paitent is given a tst feed after weaning off form ventilator. If tolerates, then
start on oral feed of light fluids in small amount and as patient tolerates well,
light semi-solid meal is given. Record the intake and output in the flow chart in
ICU. Record daily weight. If the patient's condition stabilizes well, urinary
catheter and other drainage tubes are removed.

The patient is gradually ambulated.

Prevention o f Infection
Strict asepsis practiced in ICU.
All the.invasive lines are covered with sterile-drape.
Antibiotics-broad-spectrum ones are administered, through IV line
introduced into large veins. This IV catheter left in position even when the
patient is transferred out of ICU, for administering medicine.
The patient is assisted for mouth care, sponge and change of clothing.
Environment is kept clean, quiet calm.
Pain Relief

Pain relieving drugs are administered as prescribed. Initially, Inj. Morphine in

small does given. Later on, the patient is placed on oral analgesic drugs regularly
as pain is felt on sternum and other body parts for a few days after surgery.

Care of' Psychoemotional Aspects

ICU area is an area which is cut off from outside world. Modem ICUs are built
in such a way that the sensory deprivation is reduced. Talk to the patient,listen to
the patient and encourage him to talk or communicate whichever way he
wants.(verbal/non-verbal)
Time wishing, having a clock, a calendar with date marked each day will help
the patient to orient to the time, day etc. Tell h i d e r that the operation is over
and helshe is in ICU, that all are there to help for hislher recovery to normal life.
Expailn how much improvement is there. Communicate to the family members
and allow them to visit the patient some time with all precautions of infection
prevention and disturbances to other patients in ICU. Never leave the patient
alone in ICU. Inform the patient that helshe will be shifted to the ward as his
condition stabilizes.

Transferring the Patient form ICU 'to Ward

The patient is made to ambulate in IC'J before shifting to ward . vitals are
stabilized. The ward nurse is explained the patient's operation done, recovery
made and further instructions to be followed in the ward before the patient is
transferred. The ward unit is prepared and the patient is received. The patient
remains in the ward for 6-10 days.
Respiratory and The patient is encouraged to
Cardiovascular Nursing
Ambulate more and more.
Continue breathing and other physiotherapy exercises.
Perform activities of daily living and appreciate whatever helshe is able to
do.
Involve family members in helping the patient and to encourage and
appreciate the activities of the paitent.
Start on normal diet in small quantity and more frequently. If salt restriction
is there, use lime to improve the taste.

By the 6th or 7th day the stitches are taken out, the IV cannula for medication is
removed, the pacing wire is removed . Keep the patent in supine position for two
hours after the removal of epicardial pacing wire, observe his pulse for bleeding
form the site, after two hours a 12 lead ECG and chest x-ray is done to see there
is no bleeding and no dysrhythmia. Special care is needed.

a) In a patient with coronary artery bypass graft. Refer Fig. 3.3

Fig. 3.3: Coronary artery bypass graft

The patient has additional dressing depending upon the place of graft removal.
The graft may be done---

Internal Mammary Artev: No additional dressing will be there. Preventing

infection to the sternal wound is very important as the supply of blood to
sternal area is reduced as the blood is diverted to the coronary artery.

Radial Artevy: Dressing over the forehead which could be removed by the
5th.or 6th day. Movement of the affected hands is encouraged. A slight
swelling may be there which will get subsided as healing takes place and
movement of the hand takes place. Instruct patient not to keep hand hanging
for a long time and to do the finder and wrist movements.

Sa~~henozi~sVeins: In some cases, the saphenous veins form both the legs are
sued for grafting. Both legs may have long incisions and dressing. The
dressings are removed by the 5th or 6th day. Swelling may developed on the
feet due to gravity pull in the circulation. 'There are special elastic stockings
of appropriate sizes, which when work give a counter-pressure and reduce
swelling. Teach the care of the legs.
 Daily wash the leg with soap and water after the stitches are removed(on1y Nursing Management of Patient
clean the area other than stitch line). When stitches are there, wipe the with Cardiac Surgery
stiches wlth antiseptic lotion and dry, apply powder and then slip the
stocking onto the legs. Wash the stockings once in 24-48 hours in light
detergent, dry and reuse. Explain ot the patient that the stocking are needed
only for three months.

During this time

Keep his feet raised on a pillow while resting in bed.

Not to keep his feet dangling or downward more than one hour at a
time, use of a stool to raise the feet.

Not to sit in one position continuously for more than one hour.

Not to sit cross-legged while sitting.

Continue doing the simple exercises for the legs-range of movements as

taught.

i
b) Patient with prosthetic valves. Refer Fig. 3.4, 3.5

1
Fig. 3.4: Illustration of a valve replacement

Fig. 3.5: Repair of an ascending aortic aneursm and aortic valve replacement
Respiratory and Teach patient and family members to listen to the sound of the prosthetic
Cardiovascular Nursing valves daily at the same time. Instruct them to continue listening it at hoe
after discharge.
Anticoagulant therapy. To prevent blood clotting on the valve, patients with
prosthetic valves require life long anticoagulant therapy. The patient is put
on oral anticoagulant after chest drainage tube is taken out. Usual drug givcn
is tab. Sintrom . The dose is adjusted according to the patient's reading.
There is need to monitor the prothrombin time (PT) at regular intervals.
Initially every week for one month, then two weekly, monthly and once is
three months. The paitent is maintained at two to two and a half times the
control, the purpose is to keep the blood thin to prevent blood clotting which
can damage the prosthetic valve. The patient may be able to get these tests
done by the nearby health center or with the help of the fainily doctor.
Instruct the paitent.
To keep enough stock of the anticoagulant drug at home see the date of
manufacturing and expiry while buying the drug, keep safely at home
beyond the each of children.
To take medicine at the same time every day on empty stomach, prefer-
ably 6p.m or 7p.m.. all family members to be aware of the timing to
remind the paitent.
To carry medicines during long travels
To keep a drug alert card with surgery done, name of the anticoagulant
taken, along with the name of the patient.
To inform the doctorsldentist beforc any surgeryltooth extraction that the
patient is on anticoagulant drug
To reduce the intake of iron and Vitamin K containing vegetables.
To test urine for any hematuria at regular intervals
Take precaution not to get injured and take prompt action in case of any
injury even if it is small cut.
To stick to the prescribed follow-up regime of the hospital where the
surgery is done.
c) Patient after cardiac transplant: Refer Fig. 3.6

Fig. 3.6: Orthotopic method of heart transplantation

 The major focus of medical and nursing care after transplantation is to Nursing Management of Patient
prevent early identification of rejection so that appropriate interventions can with Cardiac Surgery
be initiated. The major reason for transplant failure is rejection. Rejection
may be hyper-acute, acute or chronic.
H~per-acuterejection occurs at the time of transplant or within 48 hours
after transplant.
Acute rejection occurs usually occurs within one week to up to three months
after transplant.
Chronic rejection occurs form three months to longer after transplant.
Immunosuppressive agents are administered to transplant patients to prevent
rejection. The commonly used drugs are Azathioprine, coricosteriods
cyclosporine, lymphocytic immune globulin and OKT3. The last two are
used to treat acute rejection episodes. The first two are used lifelong in all
patients with transplant.
Azathioprine inhibits RNA and DNA syntheses and decrease proliferation of
immune cells.
Route: IV ,oral. 1-3mglkg body weight or as prescribed. Oral dose is
metabolized in liver.
Side-effect: Renal toxicity, hepatic toxicity, nausea, vomiting, anorexia, diarrhoea,
pancreatitis, stomatitis, leukopenia, thrombocytopenia, macrocytic anemia.
Nursing implications: Restrict h i d , maintain I/O, monitor for oedetna, a daily
weight recording, administer oral dose with meals if need be, enteral or
parenteral nutrition, teach patient and family members the measures to prevent
infectiou.

Corticosteroid
Anti-inflammotary and immuno suppressive.
Route: Oral, parenteral, dose as prescribed.
Side-eflects: sodium and fluid retention, potassium and calcium wasting, chest
infection, systemic arterial hypertension, peptic ulcer, hepatitis, impaired glucose
tolerance, cushing's syndrome, osteoporosis neutorpenia, lymphocytopenia,
delayed wound healing, opportunistic infection, headache, insomnia, muscle
wasting. depression, psychosis, thin fragile skin, stomatitis, hirsutism.
Nursing inzplications: LO& sodium, high potassium diet, supplement calcium and
phosphorus, anti-hypertensive, ambulation, deep breathing exercises, oral dose
administered with meals, antacids, teach infection control measures, anti-fungal
agents, instruct not to discontinue the medicine abruptly, renal and liver function
tests.

Cyclosporine
Immunosuppressive agent that is selective for lymphocytes mainly "T"
lymphocytes.
Route: Oral, parenteral, dose as prescribed.
Side-effects: Nephro-toxicity, systemic arterial hypertension, hyperkalemia,
anaphylaxis if administered 1V rapidly, hepatotxicity, lymphocytopenia,
opportunistic infection, tremors. paraesthesia, muscle weakness, increased
sensitivity to temperature changes.
tcespiratory and NNur-singimplications: Administer prescribed diuretics, antihypertensive. slow IV
Cardiovascular Nursing administration (over 4-6 hours), prevention of infection, breathing exercises, anti-
fungal, monitor blood sugar, BP, peripheral edema, renal and liver function test.
Muromonab CD-3 (Orthoclone, OKT-3)
A monoclonal antibody against mature T lymphocytes, OKT-3 is primarily used
to treat acute rejection episode. IV for 10-14 days. Effect nlonitorcd by T
lymphocytes count and by serum levels of OKT-3.
Adverse effect: Chills, fever lasting upto one hour. Respiratory symptoms may
occur and be life-threatening if the patient is fluid overloaded. Aseptic
meningitis, infection with cytomegalo-virus or herpes sinlples virus can occur.
Headache and flue-like symptoms may develop.
Most side-effects occur during the first two doses. To reduce some of the side-
effects, the patient may be given methylprednisolone, acetaminopen and anti-
histamine before OKT-3 is administered. Monitor the patient intensively for the
first two doses, vital every 15 minutes.
Signs and .symptoms of'aczrte rejection in heart tran.spIants patients
Sjmptoms: fatigue, lethargy, dyspnea, decreased tolerance for excrcise.
Signs: fluid retention, peripheral edcma, jugular venous distention, crackles,
pericardial friction rub, ECG changes-dysrhythmias and decreased voltage,
decreased cardiac output, hypotension, cardiac enlargcrnent.
Identify the signs and sylnptoms and assist with treatment to improve the
condition.
Endocardial biopsy is the major diagnostic test used to assess rejection. The
patient showing signs of rejection may be treated with increasing doses of
immunosuppressive agents. For prevention of infection specially pulmonary
infection-hand washing, use of aseptic technique for all invasive procedures.
Provide care that protects surface barriers form organism-mouth care after every
meal, upon rising and at bed time, cleaning the skin folds by daily washing,
lubricating and keeping moisture free.
Deep breathing exercises two hourly. Adequate nutrition, fluid intake. Avoid
contact with the patient if care giver is with active infection.
Patient crnd Fan~il~v
teaching

Medications
@ Dietary restriction to be maintained.
@ Infection prevention.
Follow-up schedule.
Complications of Cardiac Surgery
Usually occur during the initial 24-72 hours, but may occur later
I)~:~rhj~thmias:
on also. The causes may be ventricular irritability due to manipulations of heart
during cardiac surgery, hyper or hypokalemia, hypotension leading to decreased
blood supply to the coronary arteries causing myocardial ischemia/hypoxia. The
common dysrhythmias occurring may be bradycardias, ventricular standstill, VF
or VT, or over riding tachydsrhythmias. Treatment is as for dysrhythinias or
connecting the pacing wires inserted to temporary pacemaker as needed. Rarely,
patients may need permanent pacemaker.
 Hemorrhage; Occurs generally within the first few hours after surgery. If chest Nursing Management of Patient
drainage is more than 70ml/hour, be more alert as the patient may require with Cardiac Surgery
interventions for heamorrhage, which may include administration of protamine
sulphate, fresh frozen plasma or blood.
Cardiac Tamponade: Suspect cardiac tamponade if there is a sudden cessation of
chest drainage during immediate post-operative period. The blood is getting
collected in the pericardial space or mediastinurn, compressing the heart that
decreases the diastolic filling and therefore cardiac output. It can also be due to
clot blocking the chest tube preventing drainage. Treatment is opening of sternal
suture line and manual removal of clotted material. The patient may be wheeled
back to O.T.
Low Curdiac Output: Decrease in perfusion creating pallor, vasoconstriction and
a drop in peripheral arterial pressure. This can occur during and post-operatively
phase. Causes may be hypovolemia, MI, CHF, dysrhythmias, tamponade or
pulmonary emboli. Treatment is to identifi the cause and treat accordingly.
Atelectasis and Pnezrmonia: Signs and symptoms are LV failure, hypovolemia,
hypervolemia or renal vasoconstriction. Decreased breath sounds, poor ABG and
poor cough reflex are seen. The causes may be underlying respiratory disease
(COPD), decreased chest expansion and respiratory depression, pulmonary
oedema, perfusion/ventilation defect, thrombo emboli. Treatment is according to
the cause and appropriate respiratory care.
Infection: Due to the many invasive monitoring techniques, ET tube, urinary
catheter, surgical interventions. Cultures of blood or sputum/urine/swab form the
wound is done to identify the infecting organism. The patient is already on
prophylactic antibiotics. After culture report, start on the appropriate antibiotics.
Follow strict principles and practice universal precautions.
Post- Cardiotomy Syndrome: This is suspected to be due to an autoimmune
response to cardiac surgery. Febrile episode pericardial effusion with or without
pericardial chest pain are the common manifestation. Treatment as per sings and
symptoms.
Other complications which can occur are renal insufficiency, stress ulccrs,
embolism, convulsions/hemiplegia. Treatment is according to the cause and
manifestations.
Check Your Progress 4

1) List the steps of weaning off from ventilator.

...........................................................................................................................
2) List the pressure monitored in ICU for the first 48 hours after the surgery.
............................................................................................................................

/ 3) What is the purpose of anticoagulant therapy in patlents with prosthetic

valves and what 1s monitored in such patient?
I ...........................................................................................................................
i
I
............................................................................................................................
............................................................................................................................
Respiratory and
Cardiovascular Nursing 4) List two complications after cardiac surgery in relation to:
a) cardiac.

........................................................................................................................
b) respiratory.

c) fluid and electrolyte.

5) Name two commonly used anti-rejection drugs, following heart transplant.

3.6 REHABILITATION OF CARDIAC SURGICAL

PATIENTS
The goal of nursing care of cardiac surgical patient is to make the patient to
come back to his normal activities. Cardiac surgical rehabilitation starts along
with the pre-operative preparation and teaching. The breathing exercises. range
of motion exercises, the cleanliness and infection prevention measures, all lead
to a better post-operative life.

How to help further by further explanation regarding each aspect.

Hoine preparation.

How to get the room ready for the patient at home?

Clcan the room and all the furniture, removal all the unwanted from the room.
Make the room dust-free. Use clean bed sheets and daily wet mopping to be
done.

Travel Back to Home

Many a surgical patient may have come to hospital from distant areas as cardiac
surgery is not done in all hospitals. Generally, the patient is advised to stay near
to the hospital where surgery is done for one or two weeks to have the first
follow-up in the OPD. The sternal wiring is removed, patient is assessed and
further advised and the date for the next follow-up is given. This stay also helps
the patient to gradually adjust to the environment other than the hospital. Make
arrangement for comfortable travel. Avoid vehicles which give lot of jerks during
travel. Car, bus (if not crowded), train or air journey may be planned. During
long distance travel, continue the exercises taught at regular intervals. Take
precaution from getting any hit on the chestisternal area. The sternum takes
about 8-12 weeks for proper healing. Avoid crowed and polluted places. Use a
mask when in such places to prevent inhaling the polluted air.
,4t honze: Restrict the number of visitors at home, as the patient needs rest. Avoid
people with upper respiratory infection. Use the comfortable position for sleep.
Side lying position may not be comfortable. The patient may hear the crackling
sound of sternum while moving during sleep, tell himlher not to worry about it.
Diet: Continue diet as prescribed at hospital. Some may continue fluid and salt Nursing Management of Patient
with Cardiac Surgery
restriction, some may have to restrict iron and Vitamin K rich food stuff. The
patient needs to take easily digestible food in small amount with more frequency
initially, then gradually adjust to normal meal pattern. Take a light diet in the
night. Do not go to bed with a heavy stomach. Monitor the weight and urinary
output. A sudden increase in weight may be indicating fluid retention.
Medication: The patient is advised to continue antibiotics for a week more after
discharge. Other medications prescribed are analgesics (acetaminopen), cough
syrup, diuretics and digoxin in some patients and anticoagulants in valve
replacement cases (Sintrom). Teach the patient how to count pulse for one full
minute before discharge and advice him to note his pulse every day at the same
time and also note any changes in the rate or rhythm. Explain about each
medicine, how to take it, side-effects, safe keeping at home etc. and when not to
take medicine.
Bathing: Instruct the family members to assist the patient initially to take bath.
Once the stitches are out, the patient can take bath sitting on a stool. Somebody
has to be nearby in case any assistance is required. Taking a bath can tire the
patient in the initial period (one month). Apply soap on a soft cloth and clean the
sternal area, wash it and dry the area. No powder to be applied. Change clothes
daily. In case of venous graft taken, the leg should be cleaned and dried. Apply
powder on the legs, but not on the stitch line area. This will help to slip the
stockings on the legs.
Exercises and amhulation: Continue taking all exercises taught in the hospital.
Steam inhalation may be continued. Walk on levelled space first, gradually
increase the distance and speed of walking. In three to six months' time, he
should be able to do walking or jogging as the condition permits. If the patient
stays on an upper flat where there is no lift, climb the steps slowly. Three to four
steps at a time, take rest for a minute then climb. As condition improves and
permits, he can climb more steps in one stretch.
Health Teachnings on Do k and Dont k
Not to bend suddenly, not to pull or push towards or away from the body of
heavy furniture or doors or windows etc. as these can exert a strain on the
sternum and delay healing, not to lift anything weighing more than 5 kg for 3 to
6 months. Avoid walking in extreme weather.
Advise on Rest, recreation, sleep
The patient should take enough rest and get good sleep. Restrict the visitors so
that the patient can get enough rest. Not to strain the eyes by watching too much
of T.V. or reading, can watch light programmes or light reading, indoor games.
Avoid seeing programmes which can cause tension such as football matches,
tragic movie scenes etc. Keep the home environment conductive to his recovery.
Encourage and allow the patient to do light work such as tending for plants,
setting the dining table, helping children in their study etc. This will help the
patient to develop confidence. Patient is told that he may have fever (100-101
degree F) for a few days more and it will come down to normal in a few days
and he is getting antibiotics.
Some patients may become dep;es.;ed, emntlonally upset or even go into more
serious psychological probienis needing assistance of a psychiatrist. Family
members has to bear with the patient's behaviour, they have to appreciate,
encourage and engage the patient in self care and other home activities. The
emotional upset is a proble'm for short duration. With good care, attention and
activity, the patient will recover.
Respiratory and As the patient becomes confident and stronger, helshe can gradually increase
Cardiovascular Nursing activities and reach the normal or near normal level. In two to three months,
most patients are able to return to work.
Addvice on Follow up

The patient should adhere to the follow-up schedule strictly. Generally, one week
after discharge, then one month and then 3 to 6 months interval, the patient is
seen by the surgeon who operated the patient. In case of any problems like fever
above 10lOc,bleeding, breathlessness, dysrhythmia, the patient should report
back to the doctor.
Some patients may have to continue certain drugs life long e.g. SintrodAcitrom
for patients with prosthetic valves and long acting penicillin in RHD patients.
Dosage of sintrom, have to be gradually brought to maintenance level.
Monitoring of PT at regular intervals is required.
Cardiac transplant patient has to continue life-long anti-rejection drugs. They
need to continue the regular follow-up schedule.

3.7 LET US SUM UP

In this Unit, you have learnt about management of cardiac surgery patients. We
have discussed about cardiopulmonary bypass; it is a surgical procedure which
provides a mechanical means of circulating and oxygenated blood for the body
while by passing the heart and lungs during surgery on the heart. You have also
learnt about the different types of heart surgeries done which includes circulatory
cardiac surgery, structural cardiac surgery and brief discussion on the surgery of
cardiac conduction system.
We focused on preoperative management of patients undergoing cardiac surgery;
assessment of pulmonary, renal and liver functions; assessment of medicines
used, preparation for pulmonary physiotherapy, prevention of infection,
psychological support and familiarization of monitoring devices. This also
emphasized on the team approach in management of patients undergoing cardiac
surgery.
Towards the end, you have learnt about post-operative care and the
complications that these patients can have during post-operative period such as
decreased cardiac output altered fluid and electrolyte balance, pulmonary
.complications, complications due to clotting abnormalities and infection etc. and
how these complications can be observed, detected then prevented by careful and
continuous monitoring and nursing intervention.
 Nursing Management of Patient
3.8 KEY WORDS with Cardiac Surgery

PTCA Percutaneous Transluminal Coronary Angioplasty

CABG Coronary Artery Bypass Graft

P
H Hydrogen ion concentration

PCO, Partial Pressure of Carbon dioxide

PO2 Partial Pressure of Oxygen

Mitral Stenosis Thickening and contracture of the mitral valve cusps

Mitral Insufficiency Regurgitation due to incompetence and distortion of

mitral valves.

Aortic Insufficiency Regurgitation due to inflammatory lesion that

deform the flaps of aortic valve.

CVP : Central Venous Pressure

PWAP : Pulmonary Artery Wedge Pressure

LAP : Left Artial Pressure

SVO, : Pulmonary Artery Oxygen Saturation

PEEP : Positive end-expiratory Pressure

SaO, : Arterial oxygen Saturation

--

Check Your Progress 1

I) a) PDA ligation
b) Closed Mitral Valvotomy

c) Mitral Valve replacement

2) a) TOF

b) Tricuspid Atresia

I
Check Your Progress 2
1) Advantages Disadvantages
Rare or no need for antocoagulant therapy. Early calcification and tissue
degeneration.
Low thrombogenicity.
Low cost. Limited durability.

2) a) Prevent clotting of blood while it is flowing through the CPB circuit by

increasing the activated clotting time.
!
Respiratory and b) To bring the body temperature down so that,the 0, demand oi'the body
Cardiovascular Nursing is reduced.

c) To make the myocardium still so that the surgeon can do the surgery.
d) To neutralize the heparination. ..
3) Dysrhythmia, atelectasis, cerebral embolism, haemorrhage.
Check Your Progress 3

1) Pursed lip breathing, Abdominal breathing.

2) Inj. Morphine, and Inj. Phenargan

3) Shaving of whole body (chin to toe including private parts), then a Savlon
bath including hair wash, sterile clothes to. wear, bed made with sterile
sheets.
Check Your Progress 4

1) "T" piece connection and assessing patient breathing and ABG Thorough ET
suction.
Extubation.

0, via ventimask.
Off from 0,.
2) Central venous pressure.
Left atrial pressure or P A W
Systemic arterial pressure.

, Mean arterial pressure.

3) To prevent blood clotting and thereby protect the prosthetic valve.

Prothrombin time to be monitored and brought to 2 to 2% times the control
and the maintenance dose of sintrome or acitrom is decided once the PT is
brought to maintenance level.
4) a) Dysrhythmia, Cardiac Tamponade
b) Atelectasis, Pleural effusion
c) Hypovolemia, Hyperkalemia.
5) Azathioprine Cyclosporine.
Check Your Progress 5

a) Do not travel in vehicles giving jerky movements. Support the sternal wound
area with soft pillow or folded towel while coughing and taking deep
breathing exercised. Change position slowly. Do not pull or push heavy
equipinents. Do not lift more than 5 kg..weight. No sudden bending forward.

b) Avoid going to crowded and polluted places or use protective mask. keep
away from people with respiratory tract infection. Daily bath, keep the area
of incision clean and dry. Clean dress. Good oral hygiene.