NCP Cardiac Surgery : Posoperative care-coronary artery bypass graft, MIDCAB, Cardiomyoplasty, Valve Replacement

The goal of treatment for heart disease is to maximize cardiac output. Surgically this may be done by improving myocardial muscle function and blood flow through procedures such as the traditional CABG (or via less invasive procedures such as MIDCAB, percutaneous transmyocardial revascularization [PTMR], and/or port access requiring four small incisions under the left breast), wrapping the latissimus dorsi muscle around the heart, and/or repair or replacement of defective valves. Of the three types of cardiac surgery—(1) reparative (e.g., closure of atrial or ventricular septal defect, repair of mitral stenosis), (2) reconstructive (e.g., CABG, reconstruction of an incompetentvalve), and (3) substitutional (e.g., valve replacement, cardiac transplant)—reparative surgeries are more likely to produce cure or prolonged improvement.


Inpatient acute hospital on a surgical or post-ICU step-down unit.



Heart failure: chronic


Myocardial infarction


Psychosocial aspects of care

Surgical intervention

Patient Assessment Database

The preoperative data presented here depend on the specific disease process and underlying cardiac condition/reserve.


May report: History of exercise intolerance

Generalized weakness, fatigue

Inability to perform expected/usual life activities

Insomnia/sleep disturbance

May exhibit: Abnormal heart rate, BP changes with activity

Exertional discomfort or dyspnea

ECG changes/dysrhythmias


May report: History of recent/acute MI, three (or more) vessel coronary artery disease, valvular heart disease, hypertension

May exhibit: Variations in BP, heart rate/rhythm

Abnormal heart sounds: S3/S4, murmurs

Pallor/cyanosis of skin or mucous membranes

Cool/cold, clammy skin

Edema, JVD

Diminished peripheral pulses

Abnormal breath sounds: crackles

Restlessness/other changes in mentation or sensorium (severe cardiac decompensation)


May report: Feeling frightened/apprehensive, helpless

Distress over current events (anger/fear)

Fear of death/eventual outcome of surgery, possible complications

Fear about changes in lifestyle/role functioning

May exhibit: Apprehension, restlessness

Facial/general tension; withdrawal/lack of eye contact

Focus on self; hostility, anger; crying

Changes in heart rate, BP, breathing patterns


May report: Change in weight

Loss of appetite

Abdominal pain, nausea/vomiting

Change in urine frequency/amount

May exhibit: Weight gain/loss

Dry skin, poor skin turgor

Postural hypotension

Diminished/absent bowel sounds

Edema (generalized, dependent, pitting)


May report: Fainting spells, vertigo

May exhibit: Changes in orientation or usual response to stimuli

Restlessness; irritability, exaggerated emotional responses; apathy


May report: Chest pain, angina


May report: Shortness of breath

May exhibit: Crackles

Productive cough


May report: Infectious episode with valvular involvement or myopathy


May report: Familial risk factors of diabetes, heart disease, hypertension, strokes

Use of various cardiovascular drugs

Failure to improve

Postoperative Assessment


May report: Incisional discomfort

Pain/paresthesia of shoulders, arms, hands, legs

May exhibit: Guarding

Facial mask of pain; grimacing

Distraction behaviors; moaning; restlessness

Changes in BP/pulse/respiratory rate


May report: Inability to cough or take a deep breath

May exhibit: Decreased chest expansion

Splinting/muscle guarding

Dyspnea (normal response to thoracotomy)

Areas of diminished or absent breath sounds (atelectasis)


Changes in ABGs/pulse oximetry


May exhibit: Oozing/bleeding from chest or donor site incisions


Discharge plan DRG projected mean length of inpatient stay: 4.7 days, acute care (additional days may be considerations: divided among multiple levels of care)

Short-term assistance with food preparation, shopping, transportation, self-care needs, and homemaker/home maintenance tasks

Refer to section at end of plan for postdischarge considerations.


Hemoglobin (Hb)/hematocrit (Hct): A low Hb reduces oxygen-carrying capacity and indicates need for red blood cell replacement. Elevation of Hct suggests dehydration/need for fluid replacement.

Coagulation studies: Various studies may be done (e.g., platelet count, bleeding and clotting time) to determine therapeutic level of anticoagulant therapy when used.

Electrolytes: Imbalances (hyperkalemia/hypokalemia, hypernatremia/hyponatremia, and hypocalcemia) can affect cardiac function and fluid balance.

ABGs: Verifies oxygenation status, effectiveness of respiratory function, and acid-base balance.

Pulse oximetry: Provides noninvasive measure of oxygenation at tissue level.

BUN/creatinine: Reflects adequacy of renal and liver perfusion/function.

Amylase: Elevation is occasionally seen in high-risk patients, e.g., those with heart failure undergoing valve


Glucose: Fluctuations may occur because of preoperative nutritional status, presence of diabetes/organ dysfunction, rate of dextrose infusions.

Cardiac enzymes/isoenzymes: Elevated in the presence of acute, recent, or perioperative MI.

Chest x-ray: Reveals heart size and position, pulmonary vasculature, and changes indicative of pulmonary complications (e.g., atelectasis). Verifies condition of valve prosthesis and sternal wires, position of pacing leads, intravascular/cardiac lines.

ECG: Identifies changes in electrical, mechanical function such as might occur in immediate postoperative phase, acute/perioperative MI, valve dysfunction, and/or pericarditis.

Cardiac echocardiogram/catheterization: Measures chamber pressures and pressure gradients across valves, identifies occlusions of arteries, impaired coronary perfusion, and possible wall motion abnormalities.

Transesophageal echocardiography: Useful in diagnosing cardiac valve and chamber abnormalities, such as regurgitation, shunting, or stenosis in patients in whom transthoracic approach is not feasible.

Nuclear studies (e.g., thallium-201, DPY-thallium/Persantine): Heart scans demonstrate coronary artery disease, heart chamber dimensions, and presurgical/postsurgical functional capabilities.


1. Support hemodynamic stability/ventilatory function.

2. Promote relief of pain/discomfort.

3. Promote healing.

4. Provide information about postoperative expectations and treatment regimen.


1. Activity tolerance adequate to meet self-care needs.

2. Pain alleviated/managed.

3. Complications prevented/minimized.

4. Incisions healing.

5. Postdischarge medications, exercise, diet, therapy understood.

6. Plan in place to meet needs after discharge.