Coronary Artery Bypass Graft priority nursing care?

papawjohn · Sep 6, 2005

Hey Animaniacs

The Post-Open-Heart trade is it's own little specialty in ICU nursing. Those folks are amazing!! When I've been pulled or worked OT in their Units I've been just amazed at their complete mastery of that 36-48hr period right after the heart is restarted and the sternum wired shut. Hopefully someone from that Unit will give us a really good reply.

But here it is at 2AM and I'll take a swipe at your question.

First, follow the ACLS way of thinking: Airway, Breathing, Circulation.

Airway: Usually the CABGs I know anything about aren't on the vent for 24hrs. They're extubated in the early AM the day following surgery (for a late case) or even the day of surgery (for an early OR). Is your Pt a COPDer or having something else going on that compromises his resps? That's #1. Your answer comes from the Swan readings (pulm pressures OK?), vent parameters (is the Peak Airway Pressure nice and low? Is he breathing on his own 'over the vent'?) Other clues come from the ChestTubes--are they patent? (You're not 'sposed to 'strip' them anymore--but they CAN clot off you know.) Has their drainage cleared, slowed and stopped on schedule?

Breathing: What do you get by suctioning the ETT? Lots of secretions? Plugs? Strong cough?

Your Surgeon is going to want this guy off the vent soon.

Circulation: It is not unheard of for a CABG gone wrong to actually CAUSE an MI. Watch for monitor changes, BP problems, CHF. Your guy was deeply chilled and then warmed up--tremendous shifts in vascular tone. You should know what his 'Systemic Vascular Resistance' is (a Swan Calculation). He should be off pressors and have normal BP, Temp and SVR. You'll be paying hourly attention to the Foley--(think of a Foley catheter as a 'uro-swan')--'cause hourly urine output describes the perfusion of all the vital organs.

One more: I have an impression that Open Heart Pts are more at risk of embolic CVAs than 'regular' post-ops. The typical stroke is of the Left Middle Cerebral Art'y. They'll be flaccid on the R and aphasic. This should be high on your list of things to check for hourly.

That should get ya off to a start. (And that's how we 'think critical care'.)

Good Luck to ya, and I hope you find critical care as fascinating as I do, it's a great career.

Papaw John

hrtprncss · Sep 6, 2005

As a student, what are the care priorities to provide and do for a patient who has had a coronary artery bypass graft surgery 24 hours ago? The patient has an endotracheal tube, a chest tube, orogastric tube, and plenty of IV meds.
This is what I have so far:
This is what I have from the book:
Assess for hyovolemia, hypotension, output from chest tubes.
Monitor fluid and electrolytes, H&H,
provide pain relief
monitor for oxygenation status
assess wounds and incision site and provide care as needed
assess for post-op complications
monitor hemodynamic pressures, cardiac output
anymore suggestions on what i should do first, second, etc would be helpful.

From what you said, this looks like the patient has had a rought night, 24 hours after a CABG and still the patient is vented....So this pt has come across some sort of complication, minute or not I'm not sure. But you basically just do a head to toe assesment...Neuro check if the pt is still sedated, if not if the pt can open eyes and follow commands, if pt can lift head off of bed to assess strength for poss of extub. then see if pt maew. .after that go to pulm check the vent setting/fio2/rr/vt/peep/ps and this morning's abg, check the lung sounds and hope that this pt is awake enuff to be on cpap and ready for a nif/vc/vt or whatever u use for weaning. next check midsternal incision, chestubes, see how much it has drained the previous night, and see if the pt is ready to have the ct to be taken out, basically less than 150cc in a shift. next pacer wires make sure it's adequately connected to pacer box and the battery is full or near full, if pacing check the rhythm and make sure it's functioning properly with complete capture as needed. while you're doing this, ur checking ur aline and ur blood pressure, ur temp and other vital signs... then check ur lines and ur swan if there is a swan and make sure ur drips are running correctly at the right rate and concentration. check and see if you still need to shoot another set of numbers or if this pt can have the swan out this morning and leave the cordis in. next check ur bowel sounds, u said the pt has an ngt, check patency, i doubt there's any feeding there yet, and depending on wether this pt is extubatable then i'd hold off on the feeding orders...next check the foley and make sure the patient has adequate urine output, greater than 30cc/h. next appreciate the saphenous vein graft sites and make sure the dressings look good and not draining. then check the pedal pulses and end ur assesment with a + 2...hopefully in the next couple of hours u can get the patient extubated and be up in the chair and having clear liquids within four hours....

hrtprncss · Sep 6, 2005

papawjohn u beat me by a few seconds, u type fast lol...

papawjohn · Sep 6, 2005

Hrtprncss, now you're following ME

P-J

HappyNurse2005, RN · Sep 6, 2005

Well, being in a cardiac surgery PCU, i see the CABG pt's after they come from ICU. 24 hours after surgery is a long time to still be on the vent. Usually they are off the vent and in PCU the next day.

in no particular order, some ideas-

airway-why still on the vent? when off the vent, they will need to cough/deep breathe, which will be painful. any smoking history? that can cause trouble (had a 4ppd smoker still on the vent after 6 months!), any other respiratory history? COPD, emphysema, etc?

infection is a biggie, too. check not only chest incision, but leg/arm incisions for infection. i've seen 3 patients in the past 3 months come back for infection of some sort. being diabetic, noncompliant, poor technique, can lead to this

education-they need to know proper wound care, diet, meds teaching, etc. teach modifying of risk factors, b/c CABG is not a cure for heart disease.

and more, but im on a time constraint at the moment, so there's just a few.

dekatn · Sep 6, 2005

As a nurse and a CABG pt., I just want to remind you, don't forget that that pt. is a person underneath all the tubing and machines. I was restrained so as not to pull anything out. During that time I was concious, could hear everything that was going on around me. I was terrified, disoriented and didn't know if I was going to live or die. I couldn't use the call light. I could hear the nurses talking and laughing at the nurses station. I don't remember one single word of reassurance. I remember feeling nauseated and being afraid if I did vomit I would aspirate and die. I was in extreme pain with no way to let staff know and nobody bothered to ask. I couldn't talk d/t to tube, but I was able to nod my head. Even though I am a nurse and the procedure had been explained to me very well, I was terrified, I know my fear affected my VS because a nurse did come to check on me, but never once spoke to me or tried to reassure me that I was o.k. I know this is not the kind of info you asked for at this time, but I couldn't help but respond. Look into your pt. eyes if they are unable to speak to you, I'm sure my nurse could have seen my fear had she taken a good look, talk to them let them know what is going on and what is going to happen , I know sometimes it's hard to be empathetic if you've never had that experience, just try to imagine what it is like to be totally dependent on someone else for all your needs and not being able to verbalize those needs. Thank you for allowing me to give you some advice from both sides.