Module 2: Cardiovascular Surgery—Caring for the Patient.

After successfully completing this module, students will be able to do the following:

 Define the preoperative and postoperative strategies that can be used to ensure patients have a
successful surgery and recovery.
 Examine how diet and exercise can be used as tools to help patients recover from cardiovascular
surgical procedures.
 Identifying the signs and symptoms of a range of complications of cardiovascular surgical
procedures.
 Describe the implications that such complications can have on the care administered by a nurse.
 Develop a strategy to deal with the instances of sudden cardiac arrest.

Introduction
Through the use of modern techniques, it is possible for surgeons not only to repair damage or
deformity of the large blood vessels but also to stop the heart, open it, and perform necessary surgery
there.

The purpose of discussion of nursing care, cardiovascular surgical patients may be considered under
three general conditions:

 Those whose heart have been opened or entered, as in surgery of the heart valves.
 Those in whom surgery is confined to the great vessels or to the exterior of the heart, as in
coarctation of the aorta, patent ductus arteriosus, aneurisms, anastomoses, and non-
perforating wounds of the myocardium.
 Those in whom surgery involves the major coronary arteries.

Preoperative Care
Most patients scheduled for cardiovascular surgery enter the hospital several days prior to surgery. This
allows for adequate time to prepare the patient for what lies ahead and adequate time for the staff to
develop a rapport with the patient. Establishing a trusting relationship with the patient will provide him
with emotional support.
A thorough assessment of the patient must be made. Many members of the health care team will be
involved in this phase of preparation.

Stages of Assessment—the assessments carried out in preoperative care include

the following:
 The physician must complete a thorough physical examination and patient history. He orders
the lab work, X-rays, ECGs, and other studies that must be done to obtain baseline data on the
patient’s immediate precondition.
 A nursing assessment of the patient must be done. This involves assessing the physical,
psychological, social and spiritual needs of the patient.
 The dietician may visit the patient to do a nutritional evaluation and teach the patient about his
new postoperative diet.
 The physical therapist may visit the patient to instruct him in the postoperative procedures for
his rehabilitation. Explanations will be given regarding the importance of advancing activity
under the supervision of the staff, and exercise routines will be taught.
 An assessment must be made of the patient’s coping mechanisms. This may be done by the
chaplain, the psychologist, or most commonly, by the nursing personnel. Poor coping
mechanisms mean increased anxiety for the patient, and increased anxiety leads to a slower
recovery. Early identification of this problem will allow the nursing staff to make provisions for it
in the nursing plan of care.

Preoperative Care –Nursing Considerations

The nursing considerations in preoperative management include the following areas:
 The nursing staff executives the physician’s orders, gathers data, and keeps the physician up to
date regarding the patient’s status.
 Patient education is implemented. The patient is instructed about his postoperative routine and
the importance of his participation and cooperation during the postoperative course.
 The patient must be fully oriented to the postoperative environment. This includes
familiarization with the monitors, machines, and equipment that will be used during the
postoperative period. If possible, give the patient a tour of the CCU and allow him to meet some
of the nursing personnel.
 Reduce patient anxiety by establishing a friendly informative, caring relationship with the
patient.

Postoperative Care
Postoperative care for patients who have had surgery of the heart or great vessels is generally much the
same as that given to other chest surgery patients. A possible exception to this generalization is care for
the patient who has had surgery of the coronary arteries.

The first 48 hours following cardiovascular surgery are the most critical, and high degree of alertness
and skills in nursing care are essential if death is to be prevented. Intensifies nursing care should
continue for at least the first five postoperative days.
Pulse, blood pressure, and respiration must be taken and recorded every 15 minutes until they stabilize,
usually after 4-8 hours.

Temperatures outside the 97 to 102F range should be reported. Higher temperatures may be an
indication of shock or cardiac decompensation.

Postoperative Care—Oxygen Therapy and Psychological

Considerations.
Oxygen is given by facemask, usually at the rate of 8 liters per minute. After the patient has fully
reacted, a nasal cannula is substituted and oxygen is continued at 4 to 6 liters per minute until the
physician orders discontinuance. Peripheral signs of cyanosis and ischemia must still be watched for,
however. Mottling or blanching of the skin in an extremity—particularly if it is accompanied by other
phenomena such as pain, numbness, tingling, or loss of motion—may indicate the presence of an
embolus and should be immediately reported.

Any signs of disorientation, such as failure to recognize a member of the family or familiar surroundings,
should be reported. A transient state of depression may be expected in the CV surgical patient. In an
occasional patient, the depression will degenerate into suicidal tendencies. Postoperative depression
maybe prevented or its intensity lessened through preoperative explanation of the upcoming procedure
and sympathetic consideration of the patient’s fears and concerns.

Postoperative Care—Positioning and Turning

Usually, the patient is kept in the dorsal recumbent position until his systolic pressure is more than 100.
On specific orders from the physician, a CV surgical patient, other than one who has had coronary artery
surgery, may be raised to a semi-Fowler position and may be turned from side to side every two hours.

A blood pressure reading must be taken immediately before and 5 minutes after the patient is raised.

If the blood pressure drops after the patient is raised, the head of the bed and the patient must be
returned to horizontal for at least 30 minutes before the procedure is repeated.

Cough
After stabilization, CV surgical patients should be encouraged to raise deeply lodged secretions by
coughing with support in the same manner as other surgical patients.

Such coughing is usually effective, but if it is not, endotracheal suctioning must be employed. Sometimes
a mucolytic agent applied in aerosol form may be helpful.

Pain
Ribs that were retracted during surgery are the major sources of postoperative pain in the CV surgical
patient. During the first 24 to 48 hours, Demerol is given on a schedule and in a quantity sufficient to
keep him reasonably comfortable but not enough to depress his mental outlook and cough reflex.

After this initial period, other causes for continued restlessness—such as oxygen deprivation, fear, and
positional discomfort—should be looked for and corrected.

Postoperative Care—Underwater Seal Drainage

Underwater Seal Drainage: Nursing care with regard to CV patients with underwater seal drainage is
generally the same as that for other chest patients with such drainage equipment in place. Drainage of
about 400 to 500 ml of bloody fluid is to be expected from heart surgery patients during the first 24
hours. Absence of drainage fluid in the water seal setup indicates that fluid may be accumulating in the
thorax. Thus, drainage volume must be carefully observed and recorded.

Temporary gastric distention is a common occurrence in CV surgical patients. The stomach is intubated
and suction applied to reduce distention and relieve any pressure exerted on the heart by the distended
stomach.

Postoperative Care—Diet
With permission of the physician, fluids may be given as soon as the patient can tolerate them. The first
fluids given should be lukewarm and should not be fruit juices, as they may cause nausea.

Cardiovascular surgical patients are normally markedly thirsty, and they will drink large quantities of
fluids. If fluid is retained, intake may have to be restricted. Nursing personnel must diligently monitor
and record fluid intake and output.
Also, it may be necessary to weigh the patient daily. The physician probably will permit returning the
patient to a soft or normal diet as soon as the patient desires solid food. Solid food should be withheld
from the coronary artery surgery patient until abdominal cramps and gas no longer persist.

Postoperative Care—Exercise
The patient, upon regaining consciousness, is encourage to breathe deeply through the nose
deliberately and quietly to ventilate and expand the lungs. Care must be taken not to tire the patient.
Other voluntary body movement and exercise are encouraged after the first 24 hours.

The patient is encouraged to comb his hair, reach for objects within normal reach, and then use a pull to
raise himself. A pull may be made from wide gauze attached to the foot of the bed and extending to
within the patient’s reach. A T-handle may be inserted or a knot tied in the end of the pull to facilitate
easier grasping. From about the 5th to the 8th day, as determined by the physician, the patient is allowed
to dangle his feet for gradually increasing lengths of time, then gradually allowed out of bed more and
more until the patient is fully mobile, usually by the 12th to 14th day.

Complications of Cardiovascular Surgery

As previously stated, the first 48 postoperative hours are the most
critical, and intensive care should be continued for several days until
the patient is out of grave danger.

Respiratory problems, hemorrhage, and shock are problems associated with any major insult to the
body. The following unit discusses complications associated with the insult to the CV system in
particular.

You will learn about a variety of conditions that clients who have had some form of cardiovascular
surgery can experience.

You will also examine the various medical and nursing and medical implications of treating patients, pre
or post cardiovascular surgical procedure.
Thrombophlebitis

Thrombophlebitis is inflammation of a vein with

blood clot formation. The slowing of blood
circulation, pressure or other injuries to vein
walls predisposes its development.

The most common sites for development of thrombophlebitis are in veins of the pelvis and legs. A
postoperative patient or any other individual who has remained still for hours at a time with relaxed
muscles and a resultant slowing of venous circulation in the legs is particularly liable to develop
thrombophlebitis. When inactivity is combined with pressure on the popliteal space and the calf of the
leg, the possibility of developing thrombophlebitis increases.

Signs and Symptoms of the Thrombophlebitis:

 Cramping pain in the calf.
 Possible redness, warmth, swelling along the course of the involved vein.
 Pain that may appear only on dorsiflexion of the foot.

Nursing Implications of Thrombophlebitis

Outlines below are the nursing implications of treating a patient with thrombophlebitis:
 Do not, under any circumstance, rub or massage the affected limb.
 Place the patient on bed rest and notify the registered nurse (RN).
 Keep the affected limb horizontal and at rest until the physician has examined the patient and
ordered specific treatment. Support the entire limb from the thigh to ankle on pillows, keeping
the limb level unless otherwise ordered. Orders for treatment may include elevation and
application of continuous massive warm, moist packs to the entire limb.
 Use a bed cradle to prevent any pressure from the bed linen.
 Be alert to any complaint or other evidence of respiratory difficulty or chest pain. A clot which is
adherent to the vein wall, or a portion of a clot, can become dislodged and be carried in the
circulation as an embolus to distant and smaller arterial blood vessels in the lungs. Sudden
dyspnea, violent coughing, or severe chest pain may be the first sign of embolism.
 Discontinue routine postoperative exercise, ambulation, deep breathing, and coughing
measures until the physician has indicated which measures are to be resumed and which
precaution are to be taken.
 Carry out all subsequent treatment and nursing care measures in a manner that will avoid
abrupt movements and any strain on the part of the patient.
 When ordered, apply anti-embolism hose or intermitted external pneumatic compression
system to give support and aid venous circulation.
  When the patient is allowed out of bed, remind him to alternate walking and resting with feet
propped on a stool to avoid pressure in the popliteal space. Prolonged standing or sitting with
no movement must be avoided. Check to see that the edge of the chair seat does not press the
popliteal space and that the patient does not sit with crossed legs.

Embolism
An embolus is a blood clot or other foreign particle
floating in the bloodstream. The embolus is usually
undetectable until it suddenly lodges in an arterial
blood vessel.

This may occur when the patient is apparently convalescing and progressing normally. If the embolus is
sufficiently large and the arterial vessel which it obstructs supplies a vital area in the lungs, heart, or
brain, the patient may die before any symptoms of embolism are detectable.

A special type of embolism, pulmonary embolism, is caused by the obstruction of a pulmonary artery by
an embolus. The most frequent cause of a postoperative pulmonary embolism is a thrombosed vein in
the pelvis or lower extremities. Therefore, measures to prevent development of thrombophlebitis are
the most important ones to take to prevent the possibly fatal complication of pulmonary embolism.

Embolism—Signs and Symptoms

The signs and symptoms of embolism are outlined below, please note that some of them may
or may not be observable:
 Sudden signs of shock and collapse.
 Sudden, sharp, stabbing chest pain.
 Sudden violent coughing and hemoptysis (spitting of blood).
 Pain, blanching, numbness, or coldness in an extremity.

Nursing Implications of Embolism

 Notify the registered nurse (RN) immediately. Ensure absolute bed rest. Elevate head of bed to
relieve respiratory distress.
 Prepare to start oxygen by mask at 6 to 8 liters per minute. Take and record blood pressure,
pulse, and respiratory.
 Prepare to give medication by injection to relieve pain and acute apprehension. A narcotic drug
such as morphine sulfate or meperidine hydrochloride is often ordered.
 Prepare to continue intensive nursing care and constant observation. (The total care of the
patient who survives a pulmonary embolism is similar to that of a patient who has had a
myocardial infarction.)

Anticoagulant Drug Therapy in Thrombophlebitis and Embolism

Anticoagulant drugs such as heparin sodium and Coumadin compounds lessen the tendency of blood to
clot. They are frequently ordered as a part of a medical management of patients who have developed
thrombophlebitis or who have survived an embolism.

 This drugs do not dissolve thrombi that have already formed, but are an important treatment
measure to prevent extension of a clot within a blood vessel or to prevent further intravascular
clot formation.
 Anticoagulant drugs act by prolonging the clotting time of the blood.
 Since a patient who has once developed thrombophlebitis may have recurrence, he may be
continued on an anticoagulant drug indefinitely as a prophylactic measure.

Medical Considerations
Drug dosage is regulated very carefully by the physician, in relation to the individual patient’s
prothrombin determination. (Prothrombin determination is a special blood test).

Certain drugs should not be given with anticoagulants. Aspirin and aspirin-like drugs increase the effect
of the anticoagulant. Phenobarbital and butazolidine decrease the effects.

Nursing Implications
Nursing personnel have a responsibility to recognize that any patient receiving an anticoagulant drug
must be closely observed for bleeding.

Bleeding may occur from the mouth, nose, urinary tract, or rectum.

Patient receiving anticoagulant therapy should be encouraged to use a soft bristle toothbrush and an
electric razor instead of a blade.

Local policy often dictates that only the RN may administer anticoagulant drugs. This is due to the
potential hazards and complicated dosage orders.

Cardiac Tamponade
Bleeding into the pericardial sac, or accumulation of fluid in the pericardial sac, results in compression of
the heart. This compression reduces heart movement, prevents adequate filling of the ventricles, and
obstructs venous return to the heart. This condition, called cardiac tamponade, is an emergency that
requires prompt relief to prevent death from circulatory failure.

The signs and symptoms of cardiac tamponade include:

 Distention of the neck veins
 Weak pulse
 Low pulse pressure

Nursing implications:
 Report signs and symptoms to the RN immediately.
 Monitor pulse and blood pressure, administer oxygen as ordered for dyspnea.
 Assist with diagnostic procedures such as chest X-ray, ECG, or cardiac catheterization.
  Assist with procedures to relieve pressure and remove fluid such as thoracotomy or needle
aspiration of the pericardial cavity.

Renal Failure
Impairment of renal function may be caused by decreased cardiac output associated with open-heart
surgery or by red blood count (RBC) hemolysis caused by the trauma of cardiopulmonary bypass.

Nursing implications when renal failure is suspected include the following:

 Strict and accurate recording of intake and output.
 Measurement of urine output on an hourly basis.
 If a urine output of less than 20 cc/hr is obtain, immediately notification should be made to the
RN.
 Routine specific gravity of urine should be performed and recorded. (Specific gravity provides
information relative to kidney function).

Myocardial Infarction
A MI may occur during the postoperative period. Symptoms, however, may be masked by the
postoperative pain being experienced by the patient.

Nursing implications include the following:

 A careful assessment of the patient’s pain must be made in order to differentiate between
routine postoperative discomfort and the pain associated with a myocardial infarction.
 If MI has occurred, nursing management of the patient will encompass both postoperative and
post-MI nursing care considerations.

Cardiac Arrest

Cardiac arrest, is defined as the sudden, unexpected

cessation of the heartbeat and circulation.

This occurs when the heart action stops entirely or the heart fibrillates. Causes of sudden cardiac death
include the following:

 Cardiac arrhythmias.
 Myocardial infarction.
 Shock.
 Drowning.
 Electrocution.
 Carbon monoxide poisoning.
 Anoxia.
Cardiac Arrest—Resuscitation
The absence of peripheral pulses and heart sounds is all that is necessary to make the diagnosis. There is
a period of about four minutes between the cessation of circulation and the onset of irreversible brain
damage.

For this reason, it is imperative that resuscitation begins immediately. Resuscitation requires that two
basic life support functions be restored:

 Blood must be pumped through the body.

 Oxygen and carbon dioxide exchange must occur.

Restoration of one without the other is not adequate.

The Role of the Nurse in Cardiac Arrest

The role of the nursing paraprofessional in cardiac arrest is one of
extreme important in saving a life, as the paraprofessional may be the
first one to observe the emergency.

It is necessary to have a well-planned course of action in mind at all times, in order to be prepared for an
emergency. The nursing paraprofessional must:

 Be proficient in cardiopulmonary resuscitation (CPR).

 Be familiar with local standard operating procedures (SOP) for “CODE” (onset of cardiac arrest)
procedures, including whom to call and how to reach them.
 Be able to locate and operate emergency equipment.
 Be ready to assist in the activities of code management at the direction of the physician or
professional nurse.

Standard Items Required for Cardiac Arrest

The following items are required for a sudden event of cardiac arrest. Nurses need to be familiar with
all items listed below:

 Emergency drugs.
 Intravenous infusion equipment.
 Needles and syringes.
 Intubation equipment, oral airways.
 Oxygen equipment.
 Suction equipment.
 Assorted dressing materials.
 There should be a defibrillator/cardiac monitor available if one is not located on or near the
crash cart.

The Identification of Cardiac Arrest

Sudden cardiac arrest and the ensuring hectic activity involved in management can be a frightening and
anxiety producing experience for nursing personnel who are unaccustomed to this type of event.

A basic understanding of what takes place during cardiac arrest will do must to alleviate that anxiety.

When a cardiac arrest has been identified:

 The person who witnesses the event or discovers the patient will call for help from his co-
workers and immediately initiate CPR.
 The co-workers will respond by initiating the procedures for “calling” a code. They will then
obtain the emergency equipment, take it to the location of the code, and relieve or assist the
individual performing CPR.

Cardiac Arrest—Help Arrives

As help begins to arrive to treat the patient, several things to happen simultaneously:

 An IV “lifeline” will be initiated.

 Blood pressure readings will be obtained.
 The patient is connected to the cardiac monitor.
 Baseline blood work is drawn to assess the patient’s status.
 An ambu bag and oxygen will replace mouth-to-mouth resuscitation. Commented [MM1]: The term “Ambu bag” refers to a
type of device known as a bag valve mask, which is used to
Cardiac Arrest—The Physician’s Role provide respiratory support to patients. The name “Ambu”
is an acronym “Artificial manual breathing unit.”
The physician in charge will make decisions based on his observations of the patient’s condition and the
response to CPR. If there is no response to CPR, the code continues, and again, several things happen
simultaneously:

 The patient will be intubated.

 Appropriate emergency drugs will be administered.
  Cardiopulmonary resuscitation is continued while the electrical activity of the heart is observed
on the cardiac monitor. If appropriate to the patient’s condition, the patient will be defibrillated.
 Blood samples are drawn repeatedly to monitor the effectiveness of the treatment. Acid-base
balance and adequacy of oxygenation are of extreme concern.

These procedures continue until the patient is stabilized or the physician makes the determination to
declare the patient dead.

Cardiac Arrest—Major Roles

The seeming confusion of people is actually a coordinated effort by a group of people, each performing
a particular task. The major roles are as follows:

 A physician will direct the activities, “managing” the code.

 A nurse will administer IV medications at the direction of the physician in charge.
 A nurse will monitor blood pressure and obtain blood samples. One individual will perform chest
compressions. One individual will administer artificial ventilations. This is normally the
anesthesia specialist, who has intubated the patient.
 One individual will act as a recorder, charting the exact time of each action performed and each
medication given. One or more individuals act as “runners,” taking specimens to the lab,
obtaining needed supplies, receiving lab reports, and so forth.

Cardiac Arrest—Conclusion
Remember, the purpose of a “code” is to attempt resuscitation of a patient whose heart has stopped
pumping effectively (fibrillation) or stopped pumping altogether. Keep this purpose in mind at all times,
and be aware of your role as a nurse.

Perhaps the most valuable piece of advice to be given during an instance of cardiac arrest is to remain
calm. If you are to become “flustered” by the event, you greatly decrease the chances of your patient’s
survival.

Finally, always remember the golden rule when it comes to cardiac arrest—if in doubt, call for help
immediately.

The key points from this module are the following:

 The first 48 hours following cardiovascular surgery are the most critical, and a high degree of
alertness and skill in nursing care are essential if death is to be prevented.
 Thrombophlebitis is inflammation of a vein with blood clot formation. The slowing of blood
circulation, pressure or other injuries to vein walls predisposes its development.
 An embolus is a blood clot or other foreign particle floating in the bloodstream. The embolus is
usually undetectable until it suddenly lodges in an arterial blood vessel.
 Cardiac tamponade, is an emergency that requires prompt relief to prevent death from
circulation failure.
 Cardiac arrest, is defined as the sudden, unexpected cessation of the heartbeat and circulation.
 The absence of peripheral pulses and heart sounds is all that is necessary to make the diagnosis.
There is a period of about four minutes between the cessation of circulation and the onset of
irreversible brain damage.
 Resuscitation requires that two basic life support functions be restores; blood must be pumped
through the body and oxygen and carbon dioxide exchange must occur.
 The role of the nursing paraprofessional in cardiac arrest is one of extreme importance in saving
a life, as the paraprofessional may be the first one to observe the emergency.