Clinical teaching on Nursing

Management of child
undergone cardiac Surgery

• SREEDEVI.T.SURESH
• 2nd year M.S.c Nursing
 TEMPERATURE
• Infusions are warmed
• respiratory gases both warmed and
humidified.
• The core temperature is monitored and safe
direct
• warming is needed for lengthy operations.
 CONT..
• To attain optimal environment, the gradient
between the skin surface and the
environmental temperature must be less
than 1.5°C.As the skin surface temperature
averages 35.5°C, the optimal
• Environmental temperature is 34°C
• (slightly higher for premature
• infants).
 CONT..
• Exposure to cold environments increases
metabolic work and caloric consumption.
• Due to limited energy reserves and thin
skin,
• prolonged exposure may rapidly cause
hypothermia.
• The operating room should be prewarmed
and the temperature kept at 20-27°C.
• Body heat may be conserved by a heating
pad, circulated warm air around the child
(bearhugger),
• infrared lamp, and warm irrigation fluids.
 FLUID
• Fluid management is divided into 3
phases:

• E F I C I T T H E RAPY
• MA I N T E N A N C E T H E R A P Y
• R E P L A C EME N T T H E R A P Y
• Total Body Water (TBW) as a percentage of
the body weight varies according to age.
• Fetus has a very high TBW, which
gradually decreases to about 75% of birth
weight for a term infant.
• TBW of Premature infants > term
infants
•
• The high fat content in overweight children
leads to decrease in TBW as a % of body
weight
• During dehydration -TBW decrease
 Deficit therapy
• Deficit therapy based on 3 components :
• a. Estimation of the severity of dehydration
• b. Determination of the type of fluid deficit
• c. Repair of the deficit.
CLINICAL EVALUATION OF
DEHYDRATION
SEVERITY OF DEHYDRATION
 MAINTAINENC E
F LUIDS
• GOAL OF MAINTAINENCE F LUIDS
• Prevent dehydration
• Prevent electrolyte disorders
• Prevent ketoacidosis
• Prevent protein degradation
• Maintenance fluid requirements may need to
be increased in children with pyrexia, excess
sweating, hypermetabolic states such as
burns or when radiant heaters or
phototherapy is used.
Maintenance fluid volume is calculated
according to body weight:
• BODY WEIGHT FLUID PER DAY
• 0 – 10 kg 100 ml/kg
• 11 – 20 kg 50 ml/kg
• > 20 kg 20 ml/kg
• E L E C T R O LY T E S MA I N T E N A
NCE
• Sodium, Potassium & Chloride are given in
maintenance fluids to replace
• losses from urine and stool. Maintenance
requirements:
• Electrolytes Requirement
• Sodium 2 -3 mEq/kg/24 hour
• potassium are given as chloride salts.
• Glucose Maintenance fluids usually contain
5%
• dextrose (D5), which provide 17 cal per
• 100 mL & close to 20% of the daily caloric
needs
 REPLACEMENT
• Replacement fluid therapy is designed to
replace
• ongoing abnormal fluid and electrolyte
losses.
• e.g. drains, ileostomy
• Best measured and replaced: any fluid
losses
• >0.5ml/kg/h needs to be replaced
• Replaced with NS / HM, or 5% human
albumin if fluid loss with high protein
content (burns)
 BLOOD LOSS
• Complete blood count must be done in
infants < 12 months of age to evaluate
• haemoglobin levels, haematocrit, and the
reticulocyte.
• Trigger threshold for blood transfusion vary
according to age, haemoglobin level,
• and other factors such as :
• Infants < 4 months require blood
transfusion if:
• Haemoglobin < 12 g/dL in first 24 hour of
life
• Haematocrit < 20% with symptoms of
anaemia with low reticulocyte count,
• Haematocrit < 30% on oxygen therapy with
continuous positive airway pressure with
• clinical signs like apnoea, bradycardia,
tachycardia and low weight gain.
• Infants >4 months require blood
• transfusion if :
• Acute loss of > 15% of estimated blood
volume
• Hypervolemia (not responding to treatment)
• Post operative anaemia (heaemoglobin < 10
g/dl)
• Pre operative haemoglobin <12g/dl in
presence of cardiopulmonary disease
• The need for intraoperative transfusion
depend on the rapidity
• and amount of blood loss, assessment of
patient's blood
• volume, pre-operative haematocrit, general
medical condition
• (presence of cardiac/lung disease, nature of
surgery and the
• risk : benefit ratio of transfusion in that
situation)
• Adequate and appropriate replacement of
blood losses is essential to reduce mortality
and morbidity in paediatric surgical patient
 COMP L I C AT ION S OF MA S S I V E
B LOOD T R A N S F U S ION
• Hypocalcemia
• Hyperkalemia
• Hypomagnesemia
• Acid base disorder
• Hypothermia
 NUTRITION
• It is very important that you follow these
guidelines. If these guidelines are not
• followed, the child's surgery will be delayed
until the end of the day or rescheduled.
• The fasting guidelines are:
• After midnight: Stop non-clear liquids and
solids (this includes any food and also hard
candy or gum)
• 6 hours before arrival: Stop infant formula
• 4 hours before arrival: Stop breast milk
• 2 hours before arrival: Stop clear liquids
(water, clear apple juice)
 PREOPREATIVE CARE
• To explain to the patient / relative the nature
of the illness,implications of the surgery and
prognosis.
• Identification of potential operative
mortality and post operative morbidity
• To assess the fitness for operation
• Identification of the risks of potential
postoperative complications and
prophylactic measures
• Planning of operation and consent
 MEDICAL HISTORY

• Birth history: full-term, pre-term

• Determine post-conceptual age
• History of previous hospitalization and
surgical
• procedure
• Concurrent medical illnes
• Respiratory history
• Recent URTI, noisy breathing, history of
intubation, sleep apnea,
• feeding problems, rapid breathing,
productive cough, purulent nasal discharge
• Allergies
 FAMILY HISTORY
• Parental history: diabetes mellitus,
preeclampsia, alcohol abuse
• Unusual reaction to surgery or anesthesia
• Malignant hyperthermia
• Sickle cell anemia
• Thalassemia
• Atypical pseudo cholinesterase
 PHYSICAL EXAMINATION
• RESRIRATORY SYSTEM
• CARDIOVASCULAR SYSTEM
• DENTITION
• SKIN RASHES
• NPO STATUS
• INVESTIGATION
 POST OPERATIVE
MANAGEMENT
• To enable a faster and successful recovery of
the patient posteratively.
• To reduce post operative mortality rate.
• To reduce length of the hospital stay.
• To provide quality care service
• The theatre team should formally hand over
the care of the
• patient to the recovery staff. The information
provided should
• include the patient’s name, age, the surgical
procedure,
• existing medical problems, allergies, the
anaesthetic and analgesics given, fluid
replacement, blood loss, urine output,
• Patient’s vital parameters, consciousness,
pain and hydration
• status are monitored in the recovery room
and supportive treatment is given.
• Patient is fully conscious.
• Respiration and oxygenation are
satisfactory.
• Patient is normothermic, not in pain nor
nauseous.
• Cardiovascular parameters are stable.
• Oxygen, fluids and analgesics have been
prescribed.
• There are no concerns related to the surgical
procedure
 COMPLICATION
• RESPIRATORY
• CARDIOVASCULAR
• PAIN
• HYPOTHERMIA AND SHIVERING
• FEVER
• WOUND CARE
• WOUND DEHISCENCE
 NURSING DIAGNOSIS
• Decreased cardiac output
• Risk for bleeding
• Impaired spontaneous ventilation
• Impaired parent child relationship
• Patients with hypoxia should be treated
urgently.
• If the patient is breathing spontaneously,
adminester oxygen at
• 15L/min, using a non breathing mask.
.
• A head tilt, chin lift or jaw thrust should
relieve obstruction
• related to reduced muscle tone.
• Suctioning of any blood or secretions may
be needed.
• Inform the anaesthetist if tracheal intubation
or manual ventilation may be needed