Chapter029

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Timby/Smith: Introductory Medical-Surgical Nursing, 10/e

Timby/Smith: Introductory Medical-Surgical Nursing, 10/e

Chapter 29: Caring for Clients Undergoing Cardiovascular Surgery


• Purpose: Revascularize the Myocardium

– Repair, replace

• Cardiac valves

• Ventricular aneurysm

• Heart tumors; Heart trauma

• The heart itself

Cardiac Surgical ProceduresCardiac Surgical Procedures


Is the following statement true or false?

The purpose for cardiac surgeries is to revascularize the pericardium.

QuestionQuestion


False.

The purpose for cardiac surgeries is to revascularize the myocardium.

AnswerAnswer


Cardiac Surgical ProceduresCardiac Surgical Procedures


Myocardial RevascularizationMyocardial Revascularization

• Surgical techniques: Improve delivery of oxygenated blood to the myocardium for clients with CAD

• Risk of cardiopulmonary bypass

• Coronary artery bypass graft; Saphenous vein; Alternative graft vessels

• Conventional technique for performing CABG: Cardioplegia

• OPCAB; MIDCAB; PACAB


QuestionQuestion

Is the following statement true or false?

There are less potential complications if surgery occurs on a beating heart than if cardioplegia is utilized.


AnswerAnswer

True.

There are less potential complications if surgery occurs on a beating heart than if cardioplegia is utilized, avoiding negative “pump consequences.”


CABGCABG


Myocardial RevascularizationMyocardial Revascularization• Conventional Coronary Artery Bypass Graft

– Procedure

– Double, triple, or quadruple bypass

– Advantages; Disadvantages: Chest arteries

• Off-pump Coronary Artery Bypass (OPCAB)

– Similar to CABG

– Heart keeps beating slowly

– No bypass machine; Advantages


Myocardial RevascularizationMyocardial Revascularization• Minimally Invasive Direct Coronary Artery

Bypass (MIDCAB)

– Beating heart procedure: Minimally invasive

– Small incision: Use of endoscope

– Limitations

• Graft 1 or 2 vessels: Not obese and coronary arteries not calcified

– Eliminates risks of cardiopulmonary bypass

– Cosmetically more acceptable


Myocardial RevascularizationMyocardial Revascularization• Port Access Coronary Artery

Bypass (PACAB)

– Eliminates sternal incision

– Thorascope: Visualize the operative area after the heart is stopped

– Robotic hand; Shortened operative procedure

– Reduced mortality rates

– Full recovery is much faster


Myocardial RevascularizationMyocardial Revascularization• Valvular Repairs

– Heart valves need surgical repair when narrowed; Commissurotomy-thoracotomy procedure


Myocardial RevascularizationMyocardial Revascularization• Valvular Repairs (Cont’d)

– Valvuloplasty, annuloplasty: Tighten incompetent valves

– Mechanical valve: Excise, replace diseased valve

– Advantages of minimally invasive approaches

• Less surgical trauma; Decreased blood loss; Less mechanical ventilation

• Reduced postoperative pain; Shortened hospital stay; Improved cosmetic appearance


Myocardial RevascularizationMyocardial Revascularization• Repair of Ventricular Aneurysm

– Infracted area of myocardium balloons outward; Thrombi formation

• Lethal complication

– Motion of myocardium: Ruptures the aneurysm

– Early surgery: Difficult to differentiate healthy tissue from necrotic tissue; Sutures not retained

• Removal of Heart Tumors

– Primary tumors: Rare; Benign and malignant; Operative procedure


Aneurysm RepairAneurysm Repair


Cardiac Surgical ProceduresCardiac Surgical Procedures• Repair of Heart Trauma

– Nonpenetrating chest injury; Penetrating chest injury; Cardiac tamponade

– Thoracotomy: Control blood loss

• Heart Transplantation

– Indicated for cardiomyopathy, end-stage CAD

– Severe congenital cardiac defect in infants

– Certified candidate for transplantation

– Two methods of heart transplantation

• Orthotopic heart transplant


Cardiac Surgical ProceduresCardiac Surgical Procedures• Heart Transplantation (Cont’d)

– Rejection signs: Dose of immunosuppressives is increased

– High cost; Insurance

– CAD: Common problem

– Transplanted heart beats faster than natural heart

• 100 - 110 beats/minute

– Survival rate


QuestionQuestionIs the following statement true or false?

A transplanted heart beats at the same rate as a native heart.


AnswerAnswerFalse.

A transplanted heart beats at a faster rate (100-110 bpm) than a native heart.


Vascular Surgical ProceduresVascular Surgical Procedures• Vascular Grafts

– Used to bypass or replace diseased sections of systemic vessels: Aorta or femoral arteries

– Components of replacement graft

• Fiber; Human tissue harvested from cadavers

– Cardiopulmonary bypass

• Depends on the area involved


Vascular Surgical ProceduresVascular Surgical Procedures


Vascular Surgical ProceduresVascular Surgical Procedures• Embolectomy and Thrombectomy

– Used when thrombi or emboli occlude a major vessel

– Procedure; Emergency surgery

• Endarterectomy

– Resection and removal of the lining of an artery

– Removal of plaque from carotid, femoral, and popliteal arteries


Vascular Surgical ProceduresVascular Surgical Procedures


Hemodynamic MonitoringHemodynamic Monitoring• Assesses volume, pressure of blood in heart,

vascular system via surgically-inserted catheter

– Assess cardiac function, circulatory status; Detect fluid imbalances; Adjust fluid infusion rates; Evaluate client response to therapeutic measures

• Direct BP monitoring: Catheter in peripheral artery

• Central venous pressure (CVP); Pulmonary artery pressure (PAP); Pulmonary capillary wedge pressure (PCWP)


Nursing ProcessNursing Process• Assessment

– Client’s medical, surgical, and drug history

– Physical examination

– Client’s understanding

– Vital signs; Measure intake and output

– Signs and symptoms of potential complications

– Neurologic assessment

– Monitor IV therapy


Nursing ProcessNursing Process• Assessment (Cont’d)

– Prepare client for extensive diagnostics

– Conduct general cardiovascular assessments

– Obtain comprehensive surgical report from the anesthetist

– Assesses blood pressure

• Diagnosis, Planning, and Interventions

– Deficient knowledge; Anxiety; Acute pain

• Expected outcomes; Evaluation


End of Presentation

Chapter029

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