CABG Surgery Plan of Care

Plan of Care
CABG or coronary artery bypass graft surgery is advised in case of patients suffering from CAD (coronary artery disease). The aim of the operation is alleviating symptoms, prolonging life and improving QOL (quality of life). Every year, over 300,000 CAD- diagnosed individuals go through CABG surgeries in the US; the preliminary hospital charge for each patient is roughly 30,000 dollars. With continued improvement in surgical methods and peri- surgical care, patients who, at one time, couldn’t undergo surgery can now do so. The increased complexity of CABG cases makes it ever more critical to ensure sound collaboration between surgeons, anesthesiologists, perfusionists, nurses and other peri- surgical healthcare workers (Lamarche, Taddeo & Pepler, 1998).
CABG- related post- surgical care is a tricky business, owing to the fact that swift changes may take place in patient condition. Post- surgical care needs to take into account individual patients’ pre- surgical condition, in addition to intra- surgical events. Nursing personnel in charge of the CABG patient must predict likely complications, in order for implementing timely and proper interventions for ensuring positive patient outcomes. A range of activities are associated with patient transfer from the operation theatre to the intensive care unit or recovery room, with admitting nurses connecting patients and invasive lines with monitoring devices and another provider connecting drainage devices properly and drawing admission blood. Anesthesiologists and operation theatre nurses report patient conditions to receiving nurses (Caron & Sandra, 2006).
Numerous factors associated with heart surgery enhance likelihood of post- surgical pulmonary complications, including surgery length, ensuing increase in required anesthetics’ quantity, prolonged supine- position duration, and quantity of intra- surgical fluids administered. Atelectasis may be linked to inflammatory reaction stimulation, cardiopulmonary bypass, and surfactant inhibition (Henke & Eigsti, 2003). Both inflammatory mediators and atelectasis hamper efficient gas exchange and CO2 and O2 dissemination across alveolar capillary membranes. Lengthy pump time results in fluid shifts, thereby increasing quantity of pulmonary tissue fluid and pulmonary complication likelihood. Further, pain resulting from sternotomy may hamper breathing patterns. A few patients experience shivering (potentially a response to anesthetics or caused by the patient body making up for induced hypothermia) following CABG, which can cause lactic acidosis or increased CO2 concentrations. Moreover, shivering can enhance patients’ O2 consumption; this calls for careful monitoring and subsequent adjustment of O2 levels among patients. This is typically managed through administrating neuromuscular blockers and sedatives whilst mechanically ventilating patients (Caron & Sandra, 2006).
Case
This case involves an elderly patient (age 75 years) who was operated using the CABG method 4 days back. The surgical patient’s medical history reveals a diagnosis of chronic obstructive pulmonary disease (COPD) which was aggravated by his heavy smoking habit. The patient has endured a difficult post- surgical course, in addition to experiencing several setbacks. The patient is kept on ventilator, requires repeated suctioning all through the nurse shift, and is being monitored for potential ventilator- related pneumonia contraction.
Currently, ventilator- linked pneumonia makes up a considerable portion of nosocomial infections among trauma patients (Shorr & Kollef, 2005). Compliance with evidence- based practice (EBP) plans to prevent ventilator- linked pneumonia will serve to significantly decrease its incidence within intensive care units. Patients on mechanical ventilators display greater hospital- acquired infection development risk as compared to patients who are not. Artificial endotracheal tube or ventilator airways are capable of transmitting bacteria or viruses to lungs. Ventilator- related pneumonia among the acutely ailing is a negative health outcome as well as a matter of national public/patient safety. It increases healthcare expenditure, ventilator days, and patient mortality and morbidity rates.
The following processes prove pivotal to ventilator- related pneumonia contraction:
· Oral cavity’s bacterial colonization; and
· Aspiration of infected secretions to lower RT (respiratory tract) (Murray & Goodyear-Bruch, 2007).
· Maintenance of a 20 to 25 cm water ET- tube cuff pressure
· Bed elevation between 30 and 45 degrees
· Mouth care provision every 2 to 4 hours
Risk Factors
Nursing Management in case of Coronary Artery Bypass Graft (CABG) Surgery
Obesity, smoking, diabetes mellitus, hyperlipidemia, and heart issues in the family
Ethical and legal Issues
Nursing diagnoses
Ventilator- related pnemonia management
Diagnostic tests including Blood Tests
Priority Assessments
· Notifying higher authorities about the therapeutic plan adopted by the senior nurse
· Informed consent
· Heart Evaluation
· Oxygen saturation
· Bilateral auscultation of the lungs
· Nutrition evaluation
· Test to diagnose ventilator- linked pneumonia
· Evaluation of incision site
· Hemotocrit (Hct) and Hemoglobin (Hgb)
· Electrolytes
· Coagulation tests
· ECG
· ABGs (arterial blood gases) and
· X- ray of the chest
· Reduced cardiac output associated with weakened cardiac function
· Acute surgery-linked pain
· Open heart CABG surgery- linked infection risk
· Ventilator- linked pneumonia contraction risk
Action/Intervention
Rational
Hemodynamic Regulation
Observation and recording of blood pressure and heart rate trends, with particular emphasis on hypertension. Awareness of definite diastolic and systolic limits established for the patient.
Tachycardia represents a typical reaction to operation- related discomfort, stress and ineffective fluid/ blood replacement. But sustained tachycardia compounds cardiac workload, besides potentially decreasing effective heart output. Hypotension can arise due to fluid shortage, heart failure, shock, and dysrhythmias. Hypertension may transpire (preexisting issue or excess of fluid), pressuring the suture lines of fresh grafts and altering blood pressure or flow across valves and in heart chambers, increasing complication risks.
Noting modifications in typical mental status, physical reflexes or motion, and orientation (e.g., weakened reaction to stimuli, shock, confusion, edginess, and disorientation).
Can be a sign of reduced systemic oxygenation or cerebral flow of blood resulting from weakened cardiac output —acute or chronic dysrhythmias, heart failure, thromboembolic phenomena like perioperative stroke and low blood pressure levels
Analysis of serial echocardiograms.
Often performed for following progress in post- surgical ventricular function and electrical conduction trend normalization or for the purpose of identifying peri- surgical myocardial infarction and other similar complications
Reviewing ventilator- related pneumonia symptoms
The surgical patient has thick secretions and undergoes repeated suctioning
Administration of supplemental O2 as applicable.
Supports maximum oxygenation for decreasing cardiac workload, besides facilitating resolution of dysrhythmias and myocardial irritability.
Review of respiratory depth and rate. Record respiratory effort (e.g., dyspnea occurrence, nasal flaring, and accessory muscle usage).
Patient shows variable reactions. Effort and rate can amplify in case of fever, pain, fright, hypoxia, gastric distention, reduced circulating volume on account of fluid/blood loss, or secretion accumulation. Respiratory suppression may result owing to heavy opioid analgesic consumption or prolonged exposure to anesthesia. Timely abnormal ventilation identification and treatment can avert complications.
Auscultate breathing sounds. Determine sites of absent or reduced breathing sounds and adventitious sounds’ presence (e.g., rhonchi or crackles).
Breathing sounds commonly get diminished within lung bases for some duration following operation, the cause being typically occurring atelectasis. Such absence of active breathing sounds within prior ventilation zones can indicate a lung segment collapse, particularly in case of recent removal of chest tubes. Rhonchi or crackles can signify accumulation of fluid on account of pulmonary edema, interstitial edema, infection, or secretion accumulation-related partial airway blockage.
Making note of the nature of sputum produced, and cough.
Recurrent coughing can be caused by throat irritation due to pulmonary congestion or mere surgical ET (endotracheal tube) placement-related cough. Purulent sputum indicates pulmonary infection onset.
Elevation of the head of the patient’s bed, whether in a semi- Fowler or upright position. Aid in initial ambulation and increase in time periods spent out of bed.
Improves lung expansion and respiratory function. Successfully prevents and resolves the issue of pulmonary congestion.
(Doenges, Moorhouse & Murr, 2012).






References
Doenges, M., Moorhouse, M., & Murr, A. (2012). Nursing care plans: Guidelines for individualizing client care across the life span. Retrieved from https://eclass.teicrete.gr/modules/document/file.php/YN130/Nursing%20Care%20Plans%2C%20Edition%209%20-%20Murr%2C%20Alice%2C%20Doenges%2C%20Marilynn%2C%20Moorehouse%2C%20Mary.pdf
Caron, M., & Sandra, T. (2006). Nursing Care of the Patient Undergoing Coronary Artery Bypass Grafting. Journal of Cardiovascular Nursing. 21(2), 109 – 117.
Lamarche, D., Taddeo, R., & Pepler, C. (1998). The preparation of patients for cardiac surgery. Clin Nurs Res. 7, 390-405.
Murray, T., & Goodyear-Bruch, C. (2007). Ventilator-associated pneumonia improvement program. AACN Adv Crit Care, 18(2), 190-199.
Shorr, A., & Kollef, M. (2005). Ventilator-associated pneumonia-Insights from recent clinical trials. CHEST, 128(5), doi:10.13781/chest.128.5_suppl_2.583S