Calling all Open Heart RNs...Please help

cardiacmadeline, RN · Apr 12, 2010

I love my open heart patients (we don't do transplants) and would be happy to give you some quick words of advice. (I have to go to work soon:))

You will want to be familiar with A-fib protocol and how your CV surgeons treat it. We use amiodarone drips alot, but sometimes we replace potassium if needed and give an extra dose of metoprolol. Know your chest pain protocol and be able to differentiate between the different types of chest pain. You will need to be able to differentiate between incisional pain vs true chest pain. 9 times out of 10 when a CABG pt calls you stating they are having chest pain, it is incisional pain. A bowel regimen is important after heart surgery too, so be familiar with that. You don't want your patient to get constipated after heart surgery! Activity is important too, encourage activity and it is always a good idea to premedicate for pain beforehand. Be familiar with the external pacers and when you need to hook one up. Know where they are located on your floor and any instructions that go with them. If you need to do this, you will want the help of an experienced RN if you have no experience with them.

Some medications we use frequently: metoprolol, coumadin, colace, lasix, amiodarone, potassium, nitro (don't use alot, but you want to know about it when you do need it!).

That is just some info at the top of my head. Good luck to you!

**All Heart RN** · Apr 12, 2010

Thanks so much for your reply...your post was really helpful!

nursej22, MSN, RN · Apr 12, 2010

We don't do transplants either, but agree with above post about OHS. Other things I can add:

We get pts one day post op from CCU where they are extubated and on pressors briefly.

When they come to us they usually still have a chest tube(s), epicaridial wires and an insulin gtt to keep their blood sugars 80-150. We have a bowel prototocol (must poo before discharge), and a potassium and magnesium replacement protocol. In rare instances they may be on low dose dopamine. Everybody walks 4 times a day, incentive spirometry q1h while awake. Lots of pt teaching--sternal precautions, diabetic teaching prn, and meds.

Best Wishes!

tri-rn · Apr 12, 2010

Ask if your facility has any sort of care pathway for various OH surgery patients...ie for a post-op day 1 CABG patient who is "on" our care pathway we'll be titrating down/off pressors as able (if they're still on any), they'll be up in a chair for all meals, walking TID, on a bowel regimen, insulin gtt will still be on, you get the idea.

If your facility uses them and you can review it ahead of time it will give you an idea of what to expect and where the "ideal" patient will be. Keep in mind, not all patients experience the "ideal" recovery!

meandragonbrett · Apr 12, 2010

Meds that you'll probably give frequently include: Insulin, Plavix, ASA, Coumadin, Heparin, Lovenox, metoprolol, lisinopril, amiodarone, diltiazem, potassium and mag boluses.

Need to be familiar with epicardial pacers including indications, when to use, how to use, when to not use, etc.

Chest tubes (including mediastinal).

FlashGrad · Apr 13, 2010

The last posts hit it on the head! I just came from an open heart floor. A common occurence was pt's going into afib, often high rate. We often gave IV lopressor, mag and/or amiodarone. Also, protocols for epicardial wires getting pulled are important. I would study up on common cardiac meds too (how they work, side effects, etc) .

Good luck, working on an open heart unit made me LOVE cardiac! I also gained so much useful experience. It is always helpful to have a cardiac background, wherever you may end up. :nurse:

**All Heart RN** · Apr 13, 2010

Thanks everyone for all of the replies. I really appreciate it!

CABG patch kid, BSN, RN · Apr 13, 2010

I'm curious to know if you will be in the area where the pt is actually received immediately after surgery. If so, you should study up on your vasoactive gtts: Nitroglycerin, Nipride, Corlopam, Dobutamine, Dopamine (rarely used), and Neosynephrine. Also study IV Amiodarone and Cardizem. Common PO have been mentioned from previous posters.

A typical open heart pt in my unit: comes back from surgery straight to the unit to be recovered, accompanied by the OR team including surgeon. Immediately 2 RNs receive, attach to bedside monitor (you may have a lot of hemodynamic equipment as well) and draw stat labs. Most pts will not be put on a sedative and will be on the rapid wean protocol, meaning the RN and RT will follow a preset protocol for weaning the pt off the ventilator based on the set guidelines and the RT will extubate the pt when those are met. This happens a lot on night shift.

Once the pt is extubated, he will be trained on how to use the IS and how to splint with a pillow when coughing, as well as sternal precautions (basically they are not allowed to use their arms to pull themselves around in bed or when getting up or down from a chair). The pt will be given ice chips and diet advanced as tolerated. The goal is for the pt to be up in a chair for breakfast the morning following surgery, then to walk 3 times that day, as well as coughing and using the IS every hour.

We have a preprinted set of orders for our hearts, which allows the surgeon to go through and check off everything he wants for the pt. This includes meds, gtt, diet, PT, and what the nurse can d/c. There are parameters that allow for us to d/c the art line, swan-ganz and chest tube, nurses do not d/c epicardial wires at our facility and we only d/c mediastinal tubes, not pleural.

I would suggest grabbing a set of those preprinted orders if you have them, or asking to look at the chart of one of those pts. Looking at those orders and familiarizing myself with them is what really helped me to get a little more comfortable with taking the heart pts but I still have a long ways to go!! Good luck!

CABG patch kid, BSN, RN · Apr 13, 2010

Oh I forgot to mention: monitoring hourly outputs is really important. Milking the chest tube may be necessary to prevent it from getting stopped up from clots, especially if the pt has received any FFP, which will increase clotting. Cardiac tamponade is a major risk of surgery. You need to make sure if the output is high (usually over 100ml/hr x 2 hours) you call the MD or give blood as ordered. In some cases the pt has to go back to the OR to fix a bleeder.

Monitor urine output hourly as well, as some pts go into renal failure after surgery; all pts have fluid shifts and may need fluid, blood or Lasix depending on the situation and the surgeons preferences to keep renal perfusion going. When in doubt, ask your senior nurses!

Zookeeper3 · Apr 14, 2010

Instead of asking strangers, why don't you ask to follow a nurse for 5 hours and take all the notes you feel would help you prepare?

a cardiac surgery area is so multifaceted, that the meds, treatments alter depending upon the grafts, on pump, off pump, valve, type of bypass... it is so compicated that you have no idea what your entering in...

The fact that you need to ask shows your lack of knowledge and poor prep. So ask to follow a nurse before this as an observer, on your own time... yep on your own time and figure it out.

sound harsh... so is needing to know what to do here and I'm lacking the spoon to give it to you... if you want it that badly, get it before hand... otherwise you'll drown. Internet people can't give you what you need... prepare ahead of time. this is a fast paced live or die experience that you need to fully prepare for...this forum is the sloppy way to get a portion of it.

**All Heart RN** · Apr 15, 2010

Instead of asking strangers, why don't you ask to follow a nurse for 5 hours and take all the notes you feel would help you prepare?
a cardiac surgery area is so multifaceted, that the meds, treatments alter depending upon the grafts, on pump, off pump, valve, type of bypass... it is so compicated that you have no idea what your entering in...
The fact that you need to ask shows your lack of knowledge and poor prep. So ask to follow a nurse before this as an observer, on your own time... yep on your own time and figure it out.
sound harsh... so is needing to know what to do here and I'm lacking the spoon to give it to you... if you want it that badly, get it before hand... otherwise you'll drown. Internet people can't give you what you need... prepare ahead of time. this is a fast paced live or die experience that you need to fully prepare for...this forum is the sloppy way to get a portion of it.

Yikes:down:

My "lack of knowledge"...hmm well, you're right! I'm a new grad RN. Passed the boards on Feb 8 and began a Cardiac Internship on Feb 15...two months tomorrow. I begin my final rotation on an Open Heart floor tomorrow which will last 3 wks. The purpose of the Internship is to prepare new nurses who don't roll out of school with all of the knowledge/experience that they will need.

Not that I need to justify myself to you, especially since you seem extremely...um, well, I won't go there but I have been preparing myself, I've been studying, working my b-u-t-t off and asking questions...which brings me to the point of why I posted this question on Allnurses. I ask tons of questions to people who have experience, to people that I work with and to people online (in this case, experienced Nurses).

You've made alot of assumptions about me. I have several that I can make about you as well but I won't go there.

Relax a bit, take a deep breath....now, take a few more....maybe go on a vacation.

Thanks to everyone who was helpful. I appreciate the feedback guys and gals:)