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.
CARE SETTING
Inpatient acute hospital on a surgical or post-ICU step-down unit.
RELATED CONCERNS
Angina
Heart failure: chronic
Dysrhythmias
Myocardial infarction
Hemothorax/pneumothorax
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.
ACTIVITY/REST
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
CIRCULATION
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)
EGO INTEGRITY
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
FOOD/FLUID
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)
NEUROSENSORY
May report: Fainting spells, vertigo
May exhibit: Changes in orientation or usual response to stimuli
Restlessness; irritability, exaggerated emotional responses; apathy
PAIN/DISCOMFORT
May report: Chest pain, angina
RESPIRATION
May report: Shortness of breath
May exhibit: Crackles
Productive cough
SAFETY
May report: Infectious episode with valvular involvement or myopathy
TEACHING/LEARNING
May report: Familial risk factors of diabetes, heart disease, hypertension, strokes
Use of various cardiovascular drugs
Failure to improve
Postoperative Assessment
PAIN/DISCOMFORT
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
RESPIRATION
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)
Anxiety
Changes in ABGs/pulse oximetry
SAFETY
May exhibit: Oozing/bleeding from chest or donor site incisions
TEACHING/LEARNING
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.
DIAGNOSTIC STUDIES (POSTOPERATIVE)
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
replacement.
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.
NURSING PRIORITIES
1. Support hemodynamic stability/ventilatory function.
2. Promote relief of pain/discomfort.
3. Promote healing.
4. Provide information about postoperative expectations and treatment regimen.
DISCHARGE GOALS
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.
CARE SETTING
Inpatient acute hospital on a surgical or post-ICU step-down unit.
RELATED CONCERNS
Angina
Heart failure: chronic
Dysrhythmias
Myocardial infarction
Hemothorax/pneumothorax
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.
ACTIVITY/REST
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
CIRCULATION
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)
EGO INTEGRITY
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
FOOD/FLUID
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)
NEUROSENSORY
May report: Fainting spells, vertigo
May exhibit: Changes in orientation or usual response to stimuli
Restlessness; irritability, exaggerated emotional responses; apathy
PAIN/DISCOMFORT
May report: Chest pain, angina
RESPIRATION
May report: Shortness of breath
May exhibit: Crackles
Productive cough
SAFETY
May report: Infectious episode with valvular involvement or myopathy
TEACHING/LEARNING
May report: Familial risk factors of diabetes, heart disease, hypertension, strokes
Use of various cardiovascular drugs
Failure to improve
Postoperative Assessment
PAIN/DISCOMFORT
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
RESPIRATION
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)
Anxiety
Changes in ABGs/pulse oximetry
SAFETY
May exhibit: Oozing/bleeding from chest or donor site incisions
TEACHING/LEARNING
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.
DIAGNOSTIC STUDIES (POSTOPERATIVE)
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
replacement.
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.
NURSING PRIORITIES
1. Support hemodynamic stability/ventilatory function.
2. Promote relief of pain/discomfort.
3. Promote healing.
4. Provide information about postoperative expectations and treatment regimen.
DISCHARGE GOALS
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.
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