Aortic valve replacement, post-op course

emilyBABSNRN · Jun 5, 2011

Georgia,

I speak from experience as a tele nurse. We are the nurses that get patients usually a day after surgery and discharge the patient home. Generally patients will stay about a day in the SICU to be monitored and weaned off of the drips. Tele floors usually have ACLS nurses, though, that are drip certified. I was drip certified, so in case of hemodynamic problems, they are still prepared. Cardiac rehab is difficult and depends on the patient for how long it will last. I have seen as few as 4 days to months, with the average being about a week. No matter what reason for opening the chest cavity, whether it be for a valve repair or to do an open heart bypass surgery, they will need to place chest tubes. This means the chest's negative pressure is lost, therefore they need a way to drain the draining blood while the chest heals. This has to be drained because otherwise it places pressure on the chest cavity and the lungs can collapse. The best way to get rid of the chest tubes is to do Incentive Spirometry RELIGIOUSLY!!!!! It will hurt to do the IS becaquse the chest tubes poke a little bit, but it is so important. One tip is to make a notpad so he can keep track of his own progress. It is a big motivater for them to put a simple x on a piece of paper. As we know in nursing, it is so important to give the patient autonomy and independance. IS is important bc prevents "atelectasis" which is a big problem. This can actually cause fluid to build up in the lungs just from the normal process of breathing, and when there is fluid in the lungs that shouldnt be there, bacteria like to live there. Thus begins the problem of pneumonia. Chest tubes are uncomfortable, even if their is minimal incisional pain, they poke when doing T/C/DB but it is so important to do I. But once they come out, recovery period is usually much more comfortable and smooth. Nurses will titrate your son off of pain meds only as he is ready. Just keep in mind that it can be difficult to find the right combination of pain medication that works. Mds are reluctant to keep people on strong opioids because it causes the decreased respiratory drive, therefor increasing the risk of atelectasis and pneumonia. There is some discomfort involved that can't be avoided, but the simple fact is he has a huge advantage in having you. My best advice, and the advice the doctors and nurses will tell him is to keep moving after surgery, even if it is just his toes. Keep moving, and make sure that he does get good rest (ie limit visitors even ones that sit in the waiting room bc it is emotionally draining for patients to have to worry about others). The big thing is to get the blood flowing again and prevent blood clots. While in the hospital, no matter if the patient is in for pneumonia or for open heart, they are anticoagualted. If the heart valve is mechanic, anticoagulation is also indicated. I am sure you have heard horror stories about people being on coumadin and having bad experiences, but it is really necessary because the problems of blood clots are fatal. The nurses will teach proper precautions before discharging your son about all of this stuff. I would be happy to answer any other questions. Good luck and may God protect your stepson in his surgery. I apolgize that this posting is somewhat muddled, my keyboard has keys that get stuck!

P.S. I should also say that the "usual" day in rehab involves therapies like physical therapy teaching him how to get out of bed using a heart pillow (he wil not be able to grab anything to pull himself up, one gets out of bed by holding a pillow to the chest and moving using body weight), occupational therapy, and of course nursing. A lof of the therapy involves doing "normal" stuff, like getting in and out of bed, walking, how to eat healthy. Our goal is always to get the patient to be self-motivated to walk on their own, etc. In the beginning nurses, therapists, and therapists assistants will be there to be cheerleaders and coaches. Positive attitude and good spirits are so important in nursing and in life :) Good Luck!

MagnoliaBlossom · Jun 5, 2011

Thank you so much for your extensive refresher course!

I began life as a surgical nurse, but then went to administration then back to a simpler life in community health nursing and hospice. We deal a lot with pts on coumadin, so I'm up to speed on that, just haven't spent much time in hospitals in a while (not necessarily a bad thing :)).

I am a firm believer in visitors being extremely limited (old school, I guess) and play the heavy in most family medical situations. (we all have our gifts).

The surgery is being done at a teaching hospital which doesn't bother me because I am a product of Charity, New Orleans, but for the non-medical, it looks confusing and disorganized with all the med students, interns, residents and attendings. We have already limited two family members to patient information (meaning who the docs will communicate with) which endears us the staff and reduces the misinformation on the family grapevine.

But to provide better info to the rest of the family, many of whom are award winning drama queens, I want to have as much information on the clinic course before hand so I can better communicate the situation at hand to others (with as little blood shed as possible).

I thank you for your prayers and good wishes. It is indeed in God's hands and God is good. After all, if it were not so this potentially awful motorcycle accident would not have led us to the knowledge of David's cardiac problem. Thanks again. ga

emilyBABSNRN · Jun 5, 2011

Im sure the staff will appreciate the agreement ahead of time of who is going to get the updates from the docs :) As a Tele nurse, I have had to work with many different types of doctors and then having to answer to more than one family member is stressful because usually the questions that are asked are not easy to answer. Different teams may be managing his care at the same time and as we all know, doctors are on their own schedule and dont always keep nursing up to date on their decisions or plan. And they dont always communicate with their peers. Other thing i was going to say is don't be shocked for example if he has to be placed on an insulin drip and therefor has a specialist for that (due to the stress response, sometimes our bodies require an insulin drip but this is temporary and doesn't mean he will be diabetic afterwards...he will go back to normal). The big thing that you can do is be a motivator for him. It will be overwhelming for him being so young to go from being able to do everything by himself to having people cut his food and assist him to the bathroom. It is especially degrading for men. Don't be sad if he doesn't want you around for that :) One long-term thing to watch out for is men after heart surgeries are at big risk for depression. They don;'t talk as easily as us females, so they have a lot of bottled up emotions becuase they think they have to "take it like a man". Hospitals will have a rehab program that they continue to check in with after surgery. And I am so glad it is a teaching hospital. You might get lucky and have a nursing student assigned to you. Maybe you can contact your hospital and see if there is a former patient who can come talk to your stepson before hand and help be some extra support and give insight and advice. Hope this helps!

emilyBABSNRN · Jun 5, 2011

one last thing...since he is so young, I would not anticipate that he would need home health care. Usually if need be, pateints go to a rehab facility but this is not the norm. Usually individuals will go home, and just need help getting in and out of bed a few days after. This is because hospital beds move up and down and the ones at home dont!

nursej22, MSN, RN · Jun 5, 2011

I echo the importance of "get up and move"! Once he gets the chest tubes (there are usually 2) removed, he will be much more comfortable. They usually come out post-op (PO) day 2 or 3, depending on the amount of drainage. Our OHS patients are up in a chair for meals PO day 1 and ambulate 4 times a day by PO day 2.

He may also have epicardial wires attached to a temporary pacer. The mitral and aortic valve are near the AV conduction node and post-op edema can result in temporary heart block. Temporary pacing is sometimes needed. In rare cases a patient may need a permanent pacer.

That first BM is a big deal; sweet young things like your son seem to need more pain meds but don't want to take any laxatives or stool softeners. Just take them! And warm prune juice may taste yucky but its better than a soap suds enema any day! He won't have much appetite at first, but take the laxatives the nurse offers.

He will be on tight glucose control in the hospital and may be sent home on insulin but usually only for a week or 2, if he was not diabetic prior to surgery. The nurses will teach him how to do fingersticks and give insulin before discharge.

He will be edematous as a result of being on the heart/lung machine and diuresis will continue at home. A home scale will help to monitor fluid/weight loss. He'll get weighed every day in the hospital.

Its not unusual to have a couple of really good days and then a cr@ppy one. He may feel really good, over do and just need to recover. Or decide this is the day to stop pain meds altogether and his pain gets out of control. Its OK to have a bad day once in a while.

At his young age it's doubtful he will need home health. He will need to continue to increase his physical activity at home, usually by walking. He won't be able to drive or lift anything for about 6 weeks so plan for someone to take him for MD appointments and lab draws. In addition to anticoagulation he will be on BP meds, so a home BP monitor would be handy. A recliner may be comfortable to rest in and elevate his feet. And soft stretchy clothes like sweats will be nice until his edema is gone.

Young patients often have more post-op pain but heal faster. Best wishes!

MagnoliaBlossom · Jun 5, 2011

Emily, you are such a sweetheart.

Yes, I think depression will be a definate possibility with him. The men in his family (military) are wonderful at meeting everyone's needs around them - except their own. Very much the 'such it up' kinda guys.

I know too that he is worried about finances - just started a new job and is not covered yet by insurance so this procedure will be medicaid. Since we are 120 miles from the medical center, I am not sure which (or if) either of our two private hospitals in the area take medicaid in the cardiac rehab outpatient centers. I am going to call on Monday and see what info I can get.

Thanks for the reminder about the insulin. That was not common practice back in my hospital days and it probably would have caught me off guard.

Have a wonderful Sunday.

MagnoliaBlossom · Jun 5, 2011

Ya'll are so funny! I just about spewed my coffee on the monitor picturing him getting an enema. I worked my way through nursing school as an OB tech, so HHH enemas are my specialty Not the same thing, I understand, but it would not be a good time for me to be reminded of the time he had a party while we were out of town. Or the time that . . . - well, if ya'll are parents you know what I mean!

Thanks for the great information and the grins.

emilyBABSNRN · Jun 5, 2011

Oh yeah we cardiac nurses take pooping VERY seriously :yeah:It is really common with all of the anesthesia meds, narcotics, and just general response of the body to get plugged up. The natural stress response causes blood to be shunted away from our guts and toward our vital organs (heart)...therefore things definitley slow down. Straining to poop causes as vasovagal reflex...which includes bradycardia and sometimes worse things. SInce the heart has just been manipulated, it is really touchy. Thinkof it like a cranky heart, it has to be treated with extra TLC and it gets its feelings hurt really easily :) NO STRAINING!!! t always weirds the young ones out when the nurse asks incessently "are u passing gas?" Actually we do listen to bowel sounds, but current Evidence says that this does not matter and that the true GI integrity returns when tooting starts :) It's also really really important he eat good protein and drink lots of water. If it doesnt eat, nothing can come out, and the repairs they just did will not take as well. Nothing ****** a cardiothoraic surgeon off the most as someone who know doesnt do IS, doesn't walk, and doesnt eat. Believe me, I have seen these surgeries...it is HARD WORK! About the diabetes, I have never in my 2 years of being on a tele floor had a young patient go home on insulin unless they were overweight and probably borderline diabetic before surgery and didn't know. And a few things that might be of some comfort...although it is not too common, I have had patient in the late 30s and 40s that have needed open heart surgery...some with freakishstrains of the parainfluenza infections that destroyed their heart and other young people that have the genetic predisposition for atherosclerosis and therefore needed bypass an pacemakers. Additionally, I was told by a cardiovascular sugeron that many many people walk around with disecting aortic aneurysm and never find out. They said it's not uncommon for you to "have a leak" :) Thank God he found out this early :)

MagnoliaBlossom · Jun 5, 2011

As a hospice nurse, I am "poop obsessed" as well. Young people don't ever quite understand

the bowel function thing, but that's okay, Mother Nature has a way of reminding us how important

every little part of our bodies are.

I think I am going to print out a very basic things he needs to expect/do/be prepared for post-op. I know part of his problem will be that he is so anxious that it will be hard to concentrate and retain information, so I think I'll doo him a cheat sheet so maybe having heard it and read it, when the nurses keep bugging him, he may remember why he has to breath, move, eat, poop, etc.

Again, thank you to each of you for your support. You're on my prayer list, too!

Georgia

tcvnurse, BSN, RN · Sep 4, 2011

In our facility, he will be oob to ch on day one, as well as transferred to my step down unit. We push pulmonaryntoilet bigtime. I keep track of accomplishments on the dry erase board ( walked in hall, IS to 1250, etc). Pain management is critical for the deep breathing and coughing we will make him do. And above all STERNAL PRECAUTIONS. No pushing, pulling with arms, and I make my patients hold a pillow across their chest to keep their arms out of trouble.

Also, expect a suppository POD3.

It will amaze you how fast he recovers.