RUFAIDA COLLEGE OF NURSING

JAMIA HAMDARD

ASSIGNMENT ON

MANAGEMENT OF PATIENT’S WITH CARDIAC

SURGERIES

Submitted to: Ms. Uzma Anjum

Tutor

Submitted by: Diksha Malhotra

M.Sc. Nursing 2nd year

Submitted on: 19/02/23

Cardiac Surgery
It is an surgical procedure in which the chest is opened and surgery is performed on the heart.
The term "open" refers to the chest, not to the heart itself.

Common disorders requiring cardiac surgery

◦ coronary artery disease
◦ aortic valve disease
◦ mitral valve disease
◦ Congenital heart disease

Anatomy of Heart

The parts of heart are like the parts of a building. Heart anatomy includes:
◦ Walls.
◦ Chambers that are like rooms.
◦ Valves that open and close like doors to the rooms.
◦ Blood vessels like plumbing pipes that run through a building.
◦ An electrical conduction system like electrical power that runs through a building.

1) Heart walls
◦ Heart walls are the muscles that contract (squeeze) and relax to send blood throughout
your body. A layer of muscular tissue called the septum divides your heart walls into
the left and right sides.
◦ Heart walls have three layers:
◦ Endocardium: Inner layer.
◦ Myocardium: Muscular middle layer.
◦ Epicardium: Protective outer layer.
◦ The epicardium is one layer of your pericardium. The pericardium is a protective sac
that covers your entire heart. It produces fluid to lubricate your heart and keep it from
rubbing against other organs.

2) Heart chambers

◦ Heart has four separate chambers. Have two chambers on the top (atrium, plural atria)
and two on the bottom (ventricles), one on each side of heart.
◦ Right atrium: Two large veins deliver oxygen-poor blood to your right atrium. The
superior vena cava carries blood from your upper body. The inferior vena cava brings
blood from your lower body. Then the right atrium pumps the blood to right ventricle.
◦ Right ventricle: The lower right chamber pumps the oxygen-poor blood
to lungs through the pulmonary artery. The lungs reload the blood with oxygen.
◦ Left atrium: After the lungs fill blood with oxygen, the pulmonary veins carry the
blood to the left atrium. This upper chamber pumps the blood to left ventricle.
◦ Left ventricle: The left ventricle is slightly larger than the right. It pumps oxygen-rich
blood to the rest of body.

3) Heart valves
◦ Heart valves are like doors between heart chambers. They open and close to allow blood
to flow through. They also keep your blood from moving in the wrong direction.
◦ Atrioventricular valves
◦ The atrioventricular (AV) valves open between upper and lower heart chambers. They
include:
◦ Tricuspid valve: Door between right atrium and right ventricle.
◦ Mitral valve: Door between left atrium and left ventricle.

4) Semilunar valves
◦ Semilunar (SL) valves open when blood flows out of ventricles. They include:
◦ Aortic valve: Opens when blood flows out of left ventricle to your aorta (artery that
carries oxygen-rich blood to body).
◦ Pulmonary valve: Opens when blood flows from your right ventricle to pulmonary
arteries (the only arteries that carry oxygen-poor blood to lungs).

5) Blood vessels
◦ Heart pumps blood through three types of blood vessels:
◦ Arteries carry oxygen-rich blood from heart to body’s tissues. The exception is
pulmonary arteries, which go to your lungs.
◦ Veins carry oxygen-poor blood back to heart.
◦ Capillaries are small blood vessels where body exchanges oxygen-rich and oxygen-
poor blood.

6) Coronary arteries
◦ Heart receives nutrients through a network of coronary arteries. These arteries run
along heart’s surface. They serve the heart itself and include the:
◦ Left coronary artery: Divides into two branches (the circumflex artery and the left
anterior descending artery).
 ◦ Circumflex artery: Supplies blood to the left atrium and the side and back of the left
ventricle.
◦ Left anterior descending artery (LAD): Supplies blood to the front and bottom of the
left ventricle and the front of the septum.
◦ Right coronary artery (RCA): Supplies blood to the right atrium, right ventricle,
bottom portion of the left ventricle and back of the septum.

7) Electrical conduction system

◦ Heart’s conduction system is like the electrical wiring of a building. It controls the
rhythm and pace of heartbeat. Signals start at the top of heart and move down to the
bottom. Conduction system includes:
◦ Sinoatrial (SA) node: Sends the signals that make heart beat.
◦ Atrioventricular (AV) node: Carries electrical signals from heart’s upper chambers to
its lower ones.
◦ Left bundle branch: Sends electric impulses to left ventricle.
◦ Right bundle branch: Sends electric impulses to right ventricle.
◦ Bundle of His: Sends impulses from AV node to the Purkinje fibres.
◦ Purkinje fibres: Make heart ventricles contract and pump out blood.

Heart is in the front of your chest. It sits slightly behind and to the left of sternum (breastbone),
which is in the middle of your chest.
Heart is slightly on the left side of body. It sits between right and left lungs. The left lung is
slightly smaller to make room for the heart in left chest. Rib cage protects your heart.

Heart looks a little bit like an upside-down pyramid with rounded edges. Large blood vessels
go into and out of heart to bring blood into and away from heart. They connect heart to the rest
of body, which it supplies with blood and oxygen.

Everyone’s heart is a slightly different size. Generally, heart is about the same size as fist. On
average, an adult’s heart weighs about 10 ounces. Heart may weigh a little more or a little less,
depending on body size and sex.

Types of cardiac surgery

a. Open heart surgery

b. Closed heart surgery

Heart Lung Machine or Pump- oxygenator

◦ Operate for longer time
◦ Direct Visualisation

Cardioplegia
• To achieve this, the patient is first placed on cardiopulmonary bypass. This device, otherwise
known as the heart-lung machine, takes over the functions of gas exchange by the lung and
blood circulation by the heart. Subsequently the heart is isolated from the rest of the blood
circulation by means of an occlusive cross-clamp placed on the ascending aorta proximal to
the innominate artery.
• During this period of heart isolation the heart is not receiving any blood flow, and thus no
oxygen for metabolism. As the cardioplegia solution distributes to the entire myocardium the
ECG will change and eventually asystole will ensue. Cardioplegia lowers the metabolic rate of
the heart muscle thereby preventing cell death during the ischemic period of time.

Purposes of heart lung machine

◦ To provide the surgeon with a bloodless operating field.
◦ To perform gas exchange functions.
◦ To filter, re-warm or cool the blood.
◦ To circulate oxygenated, filtered blood back to arterial system.

I. Open heart surgery includes:

i. Valve surgery which includes valve repair and valve replacement

II. Repair of congenital defects

i. ASD & VSD

ii.TOF and Co-arction of artery

III. CABG

In CABG the veins which are used that is saphenous vein, mammary vein, IMA.

IV. Heart Transplant

Complications

◦ Haemorrhage.
◦ Shock
◦ Cardiac tamponade
◦ Renal Insufficiency & failure due to shock, haemorrhage and arteriolar
vasoconstriction during ECC procedure.
◦ Low cardiac output syndrome (results from heart failure & metabolic acidosis).
◦ Hypovolaemia (due to increase in body temp)
 ◦ Hypervolaemia (from fluid overload)
◦ Cardiac arrhythmias (from potassium imbalance, hypoxia & acidosis)
◦ Pneumothorax (inadequate lung expansion resulting from blockage of chest tubes)
◦ Wound infection
◦ Embolisation leads to convulsions, hemiplegia)
◦ Stress ulcers. (reaction of the body to prolonged physiological stress).

Perioperative preparation

There are 4 aspects covered in perioperative preparation that is;

◦ Psychological
◦ Physiological
◦ Anatomical
◦ Health teaching

PSYCHOLOGICAL PREPARATION

◦ To relieve anxiety
◦ 3 Psychological stages
o Confrontation
o Self reflection
o Resolution
◦ Give verbal/ written information concerning health care facility service.
◦ Introduce patient / relatives to health professionals.
◦ Reassure.
◦ Encourage the person to express what he feels & think

PHYSIOLOGICAL PREPARATION

◦ Laboratory Tests,(Urine, Urea, Coagulation studies, Blood grouping, Enzymes, Serum

hepatitis, VDRL, HIV).
◦ Diagnostic Studies. (ECG, Chest X-ray, Echocardiogram, Cardiac catheterisation/
angiography.
◦ Daily weight & vital signs, Apical - radial pulse (to establish baseline data).

ANATOMICAL PREPARATION

◦ Assessment of the teeth by dentist.

◦ Skin shaving from neck to toe- Anterior & lateral trunk.
◦ Several showers with anti-microbial soap.
◦ Skin prep. with betadine
◦ Any skin lesion reported to surgeon
◦ Enema in the evening.
o REMEMBER
o Anaesthetist visit.
o 4 donors to bleed on day of operation.
PRE-OPERATIVE TEACHING

◦ Chest physiotherapy & leg exercise by Physiotherapist.

◦ Explain location & importance of chest tubes.
◦ Explain that monitoring equipment will restrict movement.
◦ Explain that smoking increase chance post - operative complications.

POST-OPERATIVE CARE.
Goals Of Post - Op Care are;

1. Promote:
◦ CVS function & tissue perfusion.
◦ Respiratory, Renal & Neurologic functions.
◦ Fluid, Electrolyte, & Nutritional Balance.
◦ Rest, Comfort & Relief from pain.
◦ Early Movement & Ambulation
◦ Psychosocial Adjustment
2. Prevent:
◦ Post-operative Complications.

Intensive Care Unit

◦ Check & secure all connections for lines & tubes.

◦ Connect endo-tracheal tube to ventilator
◦ ECG to monitoring system.
◦ Patient kept flat until systolic BP is 100mmHg- Raised gradually & his response noted

1. Promote CVS Functions

◦ Assess Arterial BP & record.
◦ Irrigate Arterial line (continuous or at interval) with heparinised saline.
◦ In general BP maintained at 20 mmHg above or below baseline.
◦ Assess all pulses.

o Increased pulse in arrhythmia, shock, fever, hypoxia.

o Slow pulse in Heart block, severe anoxia.
o Apical pulse deficit in atrial fibrillation
o Absent pedal pulses in peripheral emboli
o Increased CVP in Hypervolemia, ineffective myocardial infarction
o Decreased CVP in Hypovolemia

• Record temperature if temperature is increased infection, haemolysis, atelectasis

• If temperature is decreased shock or cardiac decompensation
• Immediate 12 ECG lead
• Observe carefully for any abnormalities in ECG.

2. Promote respiratory function

◦ Adjust Rate, Tidal Volume, & 02 Level of ventilator.

 ◦ Make sure the ventilator alarms are on & functioning
◦ Observe whether persons assist the ventilator (Usually assist light will come on)
§ Observe;
§ dyspnoea
§ Airway Obstruction
§ Dyspnoea
§ Pain
§ Anoxia
§ Acidosis
§ Displaced Tube

When Patient is extubated:

1. Observe for respiratory distress.

◦ Check rate, depth, & character of respiration.
◦ Note person's colour & vital signs.
◦ ABG to determine whether patient is breathing adequately.

Prevent Pulmonary Complications like;

◦ Frequent turning & suctioning the intubated patient
◦ Help non-intubated patient to turn, take deep breaths & cough every two hours.
◦ Chest physiotherapy to rid the lungs of secretions.
◦ Report any abnormality from chest tubes.
◦ Measure drainage by collecting in calibrated cylinders
◦ Abnormal findings include:
◦ greater than 2 ml/ kg. bodyweight/ Hr.
◦ sustained haemorrhage for more than 2 minutes.
◦ Sudden cessation of chest drainage accompanied by increased CVP, dyspnoea and
oliguria.
◦ Milk chest tubes every hour to express clots.
◦ Check for kinks or bending.
◦ Prophylactic antibiotics.
◦ Daily portable chest X-ray until lung is expanded.

Promote Fluid, Electrolyte & Nutritional Balance-

◦ Prescribed I.V. fluids, blood and plasma expanders.
◦ Sips of water every 4 hourly after extubation if person is fully responsive & not
nauseated.
◦ Clear liquid first followed gradually by solid food.
◦ Watch for signs of abdominal distension and paralytic ileus.
◦ Daily electrolyte studies to determine blood levels of sodium, potassium and chloride
◦ Obtain haemoglobin level, prothrombin time and blood gasses daily.

Promote Renal Function-

1. Carefully observe & document
◦ Colour
◦ Volume - Hourly for the first 8 to 12 hours.
2. Care of indwelling Foley catheter.
Promote Comfort & Rest-
◦ Relieve pain and restlessness with comfort measures and judicious administration of
pain medication.
◦ Splint incision site during coughing and deep breathing exercise.
◦ Reassurance.

Early Movement & ambulation-

1. Turning & Exercising.
◦ - Side to side at intervals for back care
◦ Passive exercises and leg flexion every 2 hours.
2. Typical ambulation Schedule.
◦ day after surgery: dangles leg over the side of bed
◦ - 2nd. Day: sits on bed/ chair for short period.
◦ - 3rd to 5th. Day: Begins to ambulate in room
◦ 8th to 10th day: Fully ambulatory.

Discharge-
Health education:
◦ Remember: 6/52 for sternotomy to heal.
◦ Lift nothing during this period.
◦ Not to drive for 6-8 weeks.
◦ Individual's arm not to bear weight while getting out of bed or chair.
◦ Diet: Low salt & Low cholesterol.
◦ Teach person or significant others to check pulse for regularity & rate. Report to
physician for a resting heart rate rise of more than 20 beats / min.
◦ Teach person to inspect incision daily. (Betadine swab).
Medications:
◦ Label all medications.
◦ Explain purposes & side effects
◦ Pt with prosthetic valve will continue warfarin. Avoid use of aspirin... interferes with
warfarin
◦ Activities increased gradually within limits.
◦ Avoid strenuous exercise until exercise stress testing.
◦ Increase walking time and distance each day.

References-

Brunner and Siddharth, Textbook of Medical Surgical Nursing, published by John M Black,
edition 12th.
Brunner and Siddharth, Textbook of Medical Surgical Nursing, published by H.K Sharma,
edition 10th.
www.slideshare.net>careofcardiacsurgery
 RUFAIDA COLLEGE OF NURSING
JAMIA HAMDARD

ASSIGNMENT ON

CORONARY ARTERY DISEASE WITH CARDIAC

REHABILITATION

Submitted to: Ms. Uzma Anjum

Tutor

Submitted by: Diksha Malhotra

M.Sc. Nursing 2nd year

Submitted on: 19/02/23

• Definition:

◦ Coronary artery disease is the narrowing or blockage of the coronary arteries, usually
caused by atherosclerosis.

• Incidence:

◦ Cardiovascular diseases, especially coronary heart disease (CHD), are epidemic in India.
The Registrar General of India reported that CHD led to 17% of total deaths and 26%
of adult deaths in 2001-2003, which increased to 23% of total and 32% of adult deaths
in2010-2013.

• Risk factors:

• Modifiable risk factors:

◦ Tobacco use
◦ High blood cholesterol or triglyceride levels
◦ Lack of exercise
◦ Obesity
◦ Stress

• Nonmodifiable risk factors:

◦ Family history of heart disease
◦ Older age
◦ Diabetes
◦ High blood pressure

• Causes

o Coronary artery disease is thought to begin with damage or injury to the inner layer of a
coronary artery, sometimes as early as childhood.

o The damage may be caused by various factors, including:

◦ Smoking
◦ High blood pressure
◦ High cholesterol
◦ Diabetes or insulin resistance
◦ Sedentary lifestyle

• Pathophysiology:

Due to causes (e.g. high fatty diet, hereditary or

other)
 Lipid cholesterol formation on endothelium layer of
an artery

Formation of fatty streaks

Proliferation

Formation of fibrous plaque

Partial or complete blockage in coronary artery

• Symptoms:

o Cardiovascular-

◦ Angina pectoris
◦ Ischemia
◦ Low cardiac output-
◦ Bradycardia (Decrease pulse rate)
◦ Hypertension
◦ Myocardial infarction-
◦ Diaphoresis -excessive sweating
◦ ECG changes - ST segment and T wave changes, also show tachycardia, bradycardia,
or dysrhythmias.

o Respiratory-
◦ Dyspnoea
 ◦ Pulmonary Edema
◦ Chest heaviness
◦ Fatigue

o Genitourinary-
◦ Decreased Urinary Output May Indicate Cardiogenic Shock.

o Gastrointestinal-
◦ Nausea And Vomiting

o Skin-
◦ Cool, Clammy, Diaphoretic, And Pale Appearance on Skin

• Diagnostic evaluation:

◦ History collection
◦ Physical Examination
◦ Chest X ray
◦ Stress test
◦ ECG
◦ Echocardiography
◦ CT scan
◦ MRI
◦ Cardiac Catheterisation

• Complications:

◦ Chest pain (angina)

◦ Heart attack
◦ Heart failure
◦ Abnormal heart rhythm (arrhythmia)
◦ VF/VT or other dysrhythmias

• Prevention:

◦ Quit smoking
◦ Control conditions such as high blood pressure, high cholesterol and diabetes
◦ Stay physically active
◦ Eat a low-fat, low-salt diet that's rich in fruits, vegetables and whole grains
◦ Maintain a healthy weight
◦ Reduce and manage stress

Management:
o Medical management:
o Various drugs can be used to treat coronary artery disease, including:

§ Vasodilators (These drugs acts as blood vessel dilator):

◦ Nitrates
◦ Beta-Blockers (Decrease work load in heart):
◦ Propranolol 20-40 mg

§ Calcium channel blocker (They improve coronary blood flow):

◦ Nifedipine
◦ Verapamil

§ Anticoagulant Drugs:

◦ Heparin
◦ Opiate Analgesic (For reduce pain)
◦ Morphine sulphate

§ Thrombolytic Drugs:

◦ Streptokinase, Urokinase

§ Antihypertensive medicines-

◦ Methyldopa- This medication is used alone or with other medications to treat high blood
pressure (hypertension). Lowering high blood pressure helps prevent strokes, heart
attacks, and kidney problems. Methyldopa works by relaxing blood vessels so blood
can flow more easily.

◦ Sodium nitroprusside- It is used for lowering the blood pressure.

◦ Amlodipine- Amlodipine is used with or without other medications to treat high blood
pressure. Lowering high blood pressure helps prevent strokes, heart attacks, and kidney
problems. Dose-10 mg, 20 mg.

o Surgical management:

§ Angioplasty and stent placement (percutaneous coronary revascularization):

◦ A coronary angiogram is a test that uses X-rays to look at the heart's blood vessels,
called the coronary arteries. It's usually done to see if a blood vessel is narrowed or
blocked. A coronary angiogram is most often used to diagnose coronary artery disease.

◦ A coronary angiogram is part of a general group of heart tests and treatments called
cardiac catheterization. Cardiac catheterization uses one or more thin, flexible tubes,
called catheters. The tubes are placed within the major blood vessels of the body and
the heart. The test requires a small cut in the skin. During a coronary angiogram, a
treatment called angioplasty and stenting can be done to open any blocked arteries.

◦ Sometimes, a computerized tomography (CT) machine is used to look at the heart's

blood vessels. This type of angiogram doesn't need tubes placed inside the body. It's
called a coronary CT angiogram (CCTA). It may be done to determine whether
someone needs cardiac catheterization. A narrowing or blockage in the vessels cannot
be treated during a CT angiogram. If the test shows a blocked or narrowed artery, the
catheter type of coronary angiogram must be done.

o A coronary angiogram is done to look for narrowed or blocked blood vessels in the
heart and it is done due to;

◦ Chest pain, called angina.

◦ Pain in the chest, jaw, neck or arm that can't be explained by other tests.
◦ Blood vessel problems.
◦ A heart problem you were born with, called a congenital heart defect.
◦ Irregular results on an exercise stress test.
◦ Chest injury.
◦ Heart valve disease that needs surgery.
o Risks are;
◦ Blood vessel injury.
◦ Excessive bleeding.
◦ Heart attack.
◦ Infection.
◦ Irregular heart rhythms, called arrhythmias.
◦ Kidney damage due to the dye used during the test.
◦ Reactions to the dye or medicines used during the test.
◦ Stroke.

• If done in emergency;

◦ Sometimes, a coronary angiogram is done in an emergency. There may not be time to

prepare. When the test is scheduled in advance, your healthcare team gives you
instructions on how to prepare.
◦ General guidelines typically include these instructions:

◦ Do not eat or drink anything for several hours before the test. Your care team tells you
what time you need to stop eating and drinking.
◦ Ask if you can take your regular medicines. Take a list of your medicines with you to
the hospital. Include their dosages.
◦ Tell your care team if you have diabetes. You may need insulin or another medicine
before a coronary angiogram.
• Procedural Steps:

o Before procedure-

◦ A coronary angiogram is done in a hospital or medical centre in a room called a

catheterization laboratory. It's often called a Cath lab. Before the test, your healthcare
team talks to you about the medicines you take and your allergies.

◦ You change into a hospital gown and empty your bladder, if needed. Do not wear
contact lenses, eyeglasses, jewellery or hairpins.

◦ The care team checks your blood pressure and pulse. Sticky patches, called electrodes,
are placed on your chest and sometimes the arms or legs. The patches record your
heartbeat. They stay on for the entire test and for a while after.

◦ A healthcare professional may shave a small amount of hair from the area where a
flexible tube, called a catheter, will be inserted. The area is cleaned and then numbed.
o During procedure-

◦ During a coronary angiogram, you lie on your back on a table. Straps go across your
chest and legs to keep you safely on the table.

◦ A healthcare professional places an IV into a vein in your forearm or hand. Medicine

called a sedative goes through the IV. The medicine helps you feel relaxed and calm
during the test or treatment. It may make you feel sleepy.

◦ The amount of sedation you need depends on the reason for the coronary angiogram
and your overall health. You may be fully awake or lightly sedated. Or you may be
given a combination of medicines to put you in a sleep-like state. This is called general
anesthesia.

◦ The doctor makes a small cut, called an incision, to reach an artery. This cut may be
made in the leg or wrist. A thin, flexible tube called a catheter is placed in the artery
and guided to the heart. You shouldn't feel it moving through your body.

◦ Once the catheter is in the correct position, dye flows through the tube into the heart's
blood vessels. X-ray images are taken to see how the dye moves. These images are
called angiograms. If the dye doesn't move through a blood vessel, it could mean the
area is blocked or narrowed.

◦ An uncomplicated coronary angiogram may take an hour or longer to complete. It

depends on whether other heart tests or treatments are done at the same time. If a
blockage is found, a balloon may be passed through the catheter and expanded to widen
the artery. A mesh tube called a stent may be placed to keep the artery open.

◦ When the test or treatment is done, the catheter is removed from the body. A clamp or
small plug may be used to close the small incision.

o After procedure-

◦ After a coronary angiogram, you are taken to a recovery area. A healthcare team
watches you and checks your heartbeat, blood pressure and oxygen levels.
◦ If the catheter was placed in the leg area, you must lie flat for several hours. This helps
prevent bleeding. The area where the catheter was placed may feel sore for a while.
You may have a bruise and a small bump.
◦ Some people go home the same day after having a coronary angiogram. Others stay in
the hospital for a day or more, depending on the results of the test.
§ As you recover, follow these general tips:

◦ Drink plenty of fluids to help flush the dye from your body.
◦ Avoid strenuous exercise and heavy lifting for several days.
◦ Ask your healthcare team when you can bathe and shower.
◦ Take your medicines as directed by your care team.
§ Call your healthcare professional's if you have:

◦ Chest pain or shortness of breath.

◦ Bleeding, new bruising, swelling or increasing pain at the catheter site.
◦ Symptoms of infection, such as a fever.
◦ Drainage or a change in colour around the incision. This may be a shade of red, purple
or brown depending on your skin colour.
◦ A change in temperature or colour of the leg or arm that was used for the test.
◦ Weakness or numbness in a leg or arm.

§ Coronary Artery Bypass Grafting:

§ Coronary artery bypass grafting (CABG), also called heart bypass surgery, is a medical
procedure to improve blood flow to the heart. It may be needed when the arteries
supplying blood to the heart, called coronary arteries, are narrowed or blocked.

§ Your doctor may recommend the surgery to lower your risk of a heart attack if you
have coronary heart disease, or in an emergency to treat a severe heart attack.

§ CABG uses healthy blood vessels from another part of the body and connects them to
blood vessels above and below the blocked artery. This creates a new route for blood
to flow that bypasses the narrowed or blocked coronary arteries. The blood vessels are
usually arteries from the arm or chest, or veins from the legs.

§ In traditional “open heart” CABG, your heart is stopped, and a heart-lung bypass
machine takes over the job of pumping blood throughout the body. This is still the most
common approach, but other techniques, called “off-pump” procedures because the
heart does not need to be stopped, may be an option for some people.

§ As with any surgery, there are risks and possible complications. As part of
your recovery from CABG, your doctor may recommend medicines and heart-healthy
lifestyle changes to further reduce your symptoms, treat your disease, and help prevent
 complications such as blood clots. Your doctor will also talk to you about steps you can
take to prevent or lower your risk for future blockages or other problems.

§ Heart Transplant

o If your doctor recommends a heart transplant, you'll likely be referred to a heart

transplant centre for evaluation. Or you can select a transplant centre on your own.
Check your health insurance to see which transplant centres are covered under your
plan.

o When evaluating a heart transplant centre, consider the number of heart transplants a
centre performs each year and the survival rates. You can compare transplant centre
statistics using a database maintained by the Scientific Registry of Transplant
Recipients.

o You should also check to see if a transplant centre offers other services you might need.
These include coordinating support groups, assisting with travel arrangements, helping
you find local housing for your recovery period or directing you to organizations that
can help with these concerns.

• The evaluation will check to see if you:

◦ Have a heart condition that would benefit from transplantation

◦ Might benefit from other, less aggressive treatment options
◦ Are healthy enough to undergo surgery and post-transplant treatments
◦ Will agree to quit smoking, if you smoke, and stop using alcohol and recreational
drugs
◦ Are willing and able to follow the medical program outlined by the transplant team
◦ Can emotionally handle the wait for a donor heart

◦ Have a supportive network of family and friends to help you during this stressful time
o Waiting for a donor organ

◦ If the transplant centre medical team determines that you're a good candidate for a heart
transplant, the centre will put you on a waiting list. The wait can be long since there are
more people who need hearts than donors. Finding a donor depends on your size, your
blood type and how sick you are.

◦ While you're on the waiting list, your medical team will monitor your heart and other
organs and adjust your treatment as necessary. The team will help you learn to care for
your heart by eating well and being active.

◦ If medical therapy fails to support your vital organs as you wait for a donor heart, your
doctors might recommend that you have a ventricular assist device (VAD) implanted
to support your heart while you wait for a donor organ. The devices are also referred to
as bridges to transplantation because they gain you some time to wait until a donor heart
is available.

o Immediately before your transplant surgery

◦ A heart transplant usually needs to occur within four hours of organ removal for the
donor organ to remain usable. As a result, hearts are offered first to a transplant centre
close by and then to centres within certain distances of the donor hospital.

◦ Once you're notified, you and your transplant team have limited time to accept the
donation. You'll have to go to the transplant hospital immediately after being notified.

◦ As much as possible, make travel plans ahead of time. Some heart transplant centres
provide private air transportation or other travel arrangements. Have a suitcase packed
with everything you'll need for your hospital stay, as well as an extra 24-hour supply of
your medications.

◦ Once you arrive at the hospital, your doctors and transplant team will conduct a final
evaluation to determine if the donor heart is suitable for you and if you're ready for
surgery. If your doctors and transplant team decide that either the donor heart or surgery
isn't appropriate for you, you might not be able to have the transplant.

◦ Heart transplant surgery is an open-heart procedure that takes several hours. If you've
had previous heart surgeries, the surgery is more complicated and will take longer.

◦ You'll receive medication that causes you to sleep (general anesthetic) before the
procedure. Your surgeons will connect you to a heart-lung bypass machine to keep
oxygen-rich blood flowing throughout your body.

◦ Your surgeon will make an incision in your chest. Your surgeon will separate your chest
bone and open your rib cage so that he or she can operate on your heart.
◦ Your surgeon then removes the diseased heart and sews the donor heart into place. He
or she then attaches the major blood vessels to the donor heart. The new heart often
starts beating when blood flow is restored. Sometimes an electric shock is needed to
make the donor heart beat properly.

◦ You'll be given medication to help with pain control after the surgery. You'll also have
a ventilator to help you breathe and tubes in your chest to drain fluids from around your
lungs and heart. After surgery, you'll also receive fluids and medications through
intravenous (IV) tubes.

o After the procedure

◦ You'll initially stay in the intensive care unit (ICU) for a few days, then be moved to a
regular hospital room. You're likely to remain in the hospital for a week or two. The
amount of time spent in the ICU and in the hospital varies from person to person.

◦ After you leave the hospital, your transplant team will monitor you. Due to the
frequency and intensity of the monitoring, many people stay close to the transplant
center for the first three months. Afterward, the follow-up visits are less frequent, and
travel is easier.

◦ You'll also be monitored for any signs or symptoms of rejection, such as shortness of
breath, fever, fatigue, not urinating as much or weight gain. It's important to let your
transplant team know if you notice any signs or symptoms of rejection or infection.

◦ To determine whether your body is rejecting the new heart, you'll have frequent heart
biopsies in the first few months after heart transplantation, when rejection is most
likely to occur. The frequency of necessary biopsies decreases over time.

◦ During a heart biopsy, a doctor inserts a tube into a vein in your neck or groin and
directs it to your heart. The doctor runs a biopsy device through the tube to remove a
tiny sample of heart tissue, which is examined in a lab.

o Several long-term adjustments after had heart transplant. These include:

◦ Taking immunosuppressants. These medications decrease the activity of your

immune system to prevent it from attacking your donated heart. You'll take some of
these medications for the rest of your life.
§ Because immunosuppressants render your body more vulnerable to
infection, your doctor might also prescribe antibacterial, antiviral and
antifungal medications. Some drugs could worsen — or raise your risk
of developing — conditions such as high blood pressure, high
cholesterol, cancer or diabetes.
§ Over time, as the risk of rejection decreases, the doses and number of
anti-rejection drugs can be reduced.
◦ Managing medications and a lifelong care plan. After a heart transplant, taking all
your medications as your doctor instructs and following a lifelong care plan are vital.
• A daily routine for taking your medications may be helpful. Keep a list
of all your medications with you at all times for medical appointments
and in case you need emergency care. Check with your doctor before
you use any non-prescription medicines, vitamins, supplements or
herbal products.
• Your doctor might give you instructions regarding your lifestyle.
Recommendations may include wearing sunscreen, exercising, eating a
healthy diet and being careful to lower your risk of infection. You doctor
may also recommend that you not use tobacco products or recreational
drugs and limit alcohol use.
• Follow all of your doctor's instructions, see your doctor regularly for
follow-up appointments, and let your doctor know if you have signs or
symptoms of complications.

• Nursing management:

◦ Instruct the client regarding the purpose of diagnostic medical & surgical procedures and
the pre- & post procedure expectations.
◦ Assist the client to identify risk factors that can be modified, and set goals that will
promote change in lifestyle to reduce the impact of risk factors.
◦ Instruct client regarding a low-calorie, low-sodium, low-cholesterol, low-fat diet with
a increase in dietary fibre. Stress that dietary changes are not temporary and must be
maintained for life. Provide community resources to client regarding exercise, smoking
cessation and stress reduction.

o Nursing diagnosis:
◦Impaired gas exchange related to decreased blood flow as evidenced by breathlessness
◦Acute pain related to disease condition as evidenced by patient
◦verbalization
◦Impaired physical mobility related to weakness as evidenced by patient is unable to
perform daily activity.
◦ Imbalanced nutrition less than body requirement related to less intake of food as
evidenced by weight loss

• Cardiac Rehabilitation:

◦ Cardiac rehabilitation is an important program for anyone recovering from a heart

attack, heart failure, or other heart problem that required surgery or medical care.
◦ Cardiac rehabilitation is a supervised program that includes:
◦ Physical activity.
◦ Education about healthy living, including how to eat healthy, take medicine as
prescribed, and quit smoking.
◦ Counselling to find ways to relieve stress and improve mental health.
◦ A team of people may help you through cardiac rehabilitation, including your health
care team, exercise and nutrition specialists, physical therapists, and counsellors.

◦ Anyone who has had a heart problem, such as a heart attack, heart failure, or heart
surgery, can benefit from cardiac rehabilitation. Studies have found that cardiac
rehabilitation helps men and women, people of all ages, and people with mild,
moderate, and severe heart problems.2
◦ However, some people are less likely to start or finish a cardiac rehabilitation program,
including:
◦ Studies show that women, especially minority women, are less likely than men to start
or complete cardiac rehabilitation.3,4 This may be because doctors may be less likely to
suggest cardiac rehabilitation to women.
◦ Older adults. Older adults are also less likely to join a cardiac rehabilitation program
following a heart problem.5 They may think they are unable to do the physical activity
because of their age, or they may have other conditions that can make exercising harder,
such as arthritis. The need to address other physical conditions makes cardiac
rehabilitation especially useful for older adults, since it can improve strength and
mobility to make daily tasks easier.

§ Cardiac rehabilitation can have many health benefits in both the short and long term,
including:

◦ Strengthening your heart and body after a heart attack.

◦ Relieving symptoms of heart problems, such as chest pain.
◦ Building healthier habits such as getting more physical activity, quitting smoking, and
eating a heart-healthy diet. A nutritionist or dietitian may work with you to help you
limit foods with unhealthy fats and eat more fruits and vegetables that are high in
vitamins, minerals, and fibre.
◦ Reducing stress.
◦ Improving your mood. People are more likely to feel depressed after a heart attack.
Cardiac rehabilitation can help prevent or lessen depression.6
◦ Increasing your energy and strength to make daily activities like carrying groceries and
climbing stairs easier.
◦ Making you more likely to take your prescribed medicines that help lower your risk for
future heart problems.6
◦ Preventing future illness and death from heart disease. Studies have found that cardiac
rehabilitation decreases the chance that you will die in the 5 years following a heart
attack or bypass surgery by about 35%.
◦ Some programs are done in a hospital or rehabilitation centre, and other programs can
be done in your home. Cardiac rehabilitation may start while you are still in the hospital
or right after you leave the hospital.
◦ Cardiac rehabilitation programs usually last about 3 months but can range anywhere
from 2 to 8 months.

• References:
o Brunner and Siddharth, Textbook of Medical Surgical Nursing, published by John M
Black, edition 12th.
o Brunner and Siddharth, Textbook of Medical Surgical Nursing, published by H.K
Sharma, edition 10th.
o www.slideshare.net<coronaryarterydisease
o https://www.cdc.gov/heartdisease/cardiac_rehabilitation.htm