Nursing Considerations and Cardiac Surgery
Sometimes, people who come into an acute care facility for surgery have been under intensive medical treatment for weeks or years. These clients have had time to prepare physically and emotionally for the experience, and many of them welcome heart surgery as an opportunity to improve their lifestyles, realizing that often no other treatment can help them. Other clients have little or no preparation when surgery must be initiated as an emergency measure (e.g., following a severe MI). In both cases, contemporary methods of treatment and surgical techniques allow many people who have cardiac surgery to live productive lives.
The following are important considerations before surgery:
• Preoperative teaching (e.g. deep breathing, expectations after surgery)
• Discharge planning, including plans for cardiac rehabilitation
• Client’s nutrition and capacity for healing (e.g. need for supplemental protein)
• Supplemental oxygenation needs before and after surgery
• Vitamin and mineral therapy (e.g. supplemental B vitamins, iron)
• Routine tests and procedures (e.g. laboratory and radiological testing, echocardiogram, heart catheterization, ECG, cardiac biopsies)
The main objective for this preparation is to promote the client’s best possible physical condition before surgery.
Registered nurses are usually responsible for immediate postoperative nursing care; licensed practical/vocational nurses or nursing students may assist. The first 2 days after surgery are the most critical to survival. After surgery, nursing care focuses on the following:
• Maintaining airway and ventilation
• Providing adequate tissue oxygenation
• Monitoring and maintaining cardiac function
• Maintaining fluid and electrolyte balance
• Controlling chest drainage with suction
• Monitoring body temperature
• Identifying signs and symptoms of complications (e.g. infection, dysrhythmias)
• Relieving pain
NCLEX Alert Cardiovascular problems are among the most commonly seen conditions in hospitalized clients. Priority nursing concerns for NCLEX options include the ABC’s (airway breathing, circulation), nursing interventions, laboratory test results, medication uses and side effects, and teaching concepts for client and family
NURSING PROCESS
DATA COLLECTION
Carefully observe the individual with a cardiac or blood vessel disorder. Establish a baseline for future comparison to determine the presence of suspected cardiovascular complications. Report any changes in baseline observations.
A complete cardiovascular assessment begins on admission. The nursing assessment includes a complete nursing history, as well as observations. When taking the health history, ask about any potential risk factors, such as family history of cardiovascular disease, smoking, lack of exercise, or poor nutrition. Also include any issues, such as shortness of breath or fatigue, that might interfere with the client’s ability to perform activities of daily living (ADL).
Include observations of heart sounds, blood pressure, and pulse. Note any specific signs and symptoms, such as shortness of breath and edema in hands or feet, while taking the client’s vital signs (see In Practice: Data Gathering in Nursing 81-1). Observe the client’s emotional response to the disorder or disease and the person’s understanding of ongoing treatment.
PLANNING AND IMPLEMENTATION
Together, the healthcare team, client, and family plan effective care to meet the client’s individualized needs. For the client undergoing diagnostic tests, such as cardiac catheterization, and procedures, such as angioplasty, provide preoperative and postoperative care. The person with a heart or blood vessel disorder may require assistance in meeting daily needs. The person who has had a CVA (stroke) may need total assistance and nursing care temporarily or on a long-term basis. The person with a chronic disability, such as hemiplegia or a damaged heart, may need assistance in dealing with psychosocial problems. Many clients need to understand more about their disorder, its prognosis, and its treatment. A nursing care plan is developed for each client to meet his or her individual needs.
IN PRACTICE: DATA GATHERING IN NURSING 81-1
SIGNS AND SYMPTOMS OF CARDIOVASCULAR DISORDERS
• Changes in the rate, quality and rhythm of the pulse
• Rise or fall in blood pressure or central venous pressure (as can be noted by jugular venous distention)
• Edema, especially in the feet and ankles (faulty heart action causes the collection of fluids in the tissues)
• Weight gain due to excess fluid in the tissues
• Difficulty breathing and the presence of a cough, often caused by pulmonary edema
• Cyanosis, owing to a lack of oxygen in the blood or a circulatory disorder
• Clubbing of the fingers
• Needing to squat to breathe
• Pain (a significant symptom)
• Fatigue, for no apparent reason
• Intermittent claudication, which denotes a decrease in blood supply to the legs and feet (A person with arterial blockage will feel pain within 1 minute after beginning to walk.)
Teaching About Prevention
To aid in the prevention of cardiovascular disorders, teach about predisposing factors (e.g., fat buildup in the arteries, hypertension, obesity, diabetes mellitus, or smoking). The goals of prevention and treatment with many cardiovascular disorders, including hypertension, include weight reduction, if necessary; reduction or elimination of dietary intake of cholesterol and salt; maintenance of a healthy pattern of sleep, rest, and relaxation; cessation of smoking; and learning ways to handle emotional upsets. If the client is taking antihypertensive drugs, teaching involves explaining the necessity of taking the prescribed medications even if he or she feels well. Antihypertensives help relieve cardiac stress, relax blood vessels, and reduce tissue fluid and blood volume. Describe possible side effects of these medications.
Suggest a consultation with a registered dietitian, or a support group for weight loss and maintenance. Counseling about fat in the diet may be helpful.
Aerobic exercise (in moderation) is good for cardiovascular conditioning and helps in weight loss. Walking, especially at a good pace, is effective and inexpensive. The greatest exercise risk is avoiding it. Teach clients how to warm up before and cool down after exercise. Smoking cessation programs may be necessary for those who wish to stop smoking.
Clients can learn how to measure their blood pressure at home. Many authorities believe that when the person is involved in self-care more directly, he or she is more likely to comply with medications and required routines. In Practice: Educating the Client 81-1 lists teaching factors and actions individuals can take to reduce the risk of cardiovascular disease.
EVALUATION
Together, the healthcare team, client, and family evaluate outcomes of care. Have short-term goals been met? Is the client stabilized following any initial emergency? For example, have the client’s vital signs and heart rate and rhythm stabilized? Are long-term goals realistic? For example, does the client accept the diagnosis of MI and the need for lifestyle changes, or is he or she denying the problem? Will the client need long-term nursing care or short-term rehabilitation placement? Does the client need home health aide/homemaker services or regular in-home medication administration? Has the client been referred to a “stop smoking” program? Do the client and family need a support group? When planning for further nursing care, consider the client’s prognosis, as well as any complications, and the client’s responses.
IN PRACTICE EDUCATING THE CLIENT 81-1
PREVENTION OF CARDIOVASCULAR DISORDERS
♦ Stop smoking and avoid smoking’s harmful effects. Rationale: Nicotine is a vasoconstrictor. It also increases heart rate and blood pressure.
♦ Reduce sodium (salt) intake. Rationale: Salt restriction minimizes fluid retention.
♦ Maintain weight within standardized guidelines. Rationale: Obesity increases the workload of the heart.
♦ Avoid foods high in animal fats and cholesterol. Rationale: Excess blood cholesterol can form plaque in blood vessels. Plan meals using www.ChoseMyPlate.gov.
♦ Avoid foods that contain caffeine: coffee, cola drinks, tea, chocolate. Rationale: Caffeine is a potent vasoconstrictor.
♦ Exercise regularly and moderately (at least three times a week for 30 minutes). Walking is a healthful exercise. Rationale: Exercise stimulates circulation and builds cardiac strength and endurance.
♦ Avoid crossing the legs at the knees when sitting. Rationale: Crossing the legs at the knees hampers circulation.
♦ Have both feet comfortably touch the floor when sitting. Rationale: This position avoids constriction of blood vessels in the groin area.
♦ For a few minutes in the morning and evening, elevate the feet. Rationale: This position encourages venous return.
♦ Avoid constrictive garments, especially around the legs, arms, and waist. Tight-fitting garters or girdles should not be worn. Rationale: These items restrict circulation.
♦ Wear properly fitted shoes. Rationale: They prevent irritation and skin breakdown. Ulcers on the foot or leg are difficult to heal if peripheral circulation is impaired.
♦ Avoid and minimize environmental stress and anxiety-producing factors. Learn ways to handle stress effectively. Rationale: Stress causes the release of substances called catecholamines, which constrict blood vessels and thus elevate blood pressure.
♦ Follow medication regimens for prescribed medications.
♦ Get plenty of rest and relaxation. Learn relaxation techniques, if necessary
ABNORMAL CONDITIONS THAT MAY CAUSE CARDIOVASCULAR DISEASE
Some types of heart disease are curable; others are not, but they can be controlled with treatment. A client’s attitude toward heart disease affects recovery. Some people are so frightened that they are afraid to move. Others deny the seriousness of their disease and disregard orders about diet, rest, and smoking. Several types of heart conditions are discussed here that, if left untreated, can lead to more serious cardiovascular conditions. Client teaching can help individuals understand the seriousness of these conditions and the value of diet, exercise, and medication.
Arteriosclerosis and Atherosclerosis
Arteriosclerosis applies to several pathologic conditions in which the walls of the arteries thicken, harden, and lose elasticity. Sometimes it is referred to as “hardening of the arteries.” Atherosclerosis, the most common type of arteriosclerosis, is characterized by fatty deterioration of the arterial smooth muscle walls. Gradually, over several years, the walls absorb increasing amounts of circulating lipids and the lumen of the arteries narrows (stenosis) or may close completely. This buildup of fat and mineral deposits is called plaque. Often the terms arteriosclerosis and atherosclerosis are used interchangeably. These diseases may affect the heart valves and may lead to hypertension or CAD.
A diet high in saturated fat is usually associated with an increased blood cholesterol level. Studies have shown that unsaturated fats (e.g., olive oil, corn oil) do not raise the blood cholesterol level as much as saturated fats (found in butter, eggs, and meats). Some people seem to metabolize cholesterol differently than others. In treating cardiovascular disorders, the physician periodically measures the client’s blood cholesterol level and may attempt to control the amount of cholesterol through diet, medications, and exercise. The balance between high-density lipoprotein (HDL or “good” cholesterol) and low-density lipoprotein (LDL or “bad” cholesterol) is more important than is the actual total cholesterol value. However, as the total level rises above 150, a person’s risk of CAD increases.
Hypertension
Hypertension (HTN) or hypertensive heart disease means high blood pressure. One in five people in the United States have HTN.
Special Considerations : LIFESPAN
Estimates are that two thirds of all Americans older than 65 years and a growing number of children have high blood pressure. Before 65 years, HTN is more common in men, but after 65 years, it is more common in women.
Special Considerations :CULTURE & ETHNICITY
Studies show that African Americans are more likely to have HTN earlier in life, at higher levels, and twice as often as Caucasians.
Hypertension is a leading cause of MI, cardiac damage, kidney damage, congestive heart failure, and CVA. With advancing age, blood pressure tends to rise, although the exact reason is unclear. One thing is certain: the condition of the heart and blood vessels has the greatest effect on blood pressure. Although HTN cannot be cured, treatment can usually bring blood pressure to within the normal range.
High blood pressure is predominantly caused by a spasm of the small arterioles. Normal pressure gradients and normal volumes of blood are seen on the graph in Figure 81-5.
An increase in the pressure within the blood vessels can cause significant damage to small arterioles. The spasms increase blood pressure and thus contribute to arteriosclerosis (a vicious circle). Because the heart must pump harder to force blood through the arteries, the result is hypertrophy (enlargement) of the heart muscle.
Hypertension may exist owing to a known cause, such as kidney failure, malformations of blood vessels, certain tumors, and some specific endocrine disorders. However, the cause may be unknown (most cases, a condition classified as essential hypertension). Symptoms other than elevated blood pressure may not occur for years, and no restrictions are imposed until other symptoms develop. Encourage clients with HTN to exercise, observe moderation in eating, and avoid tension and anxiety. Advise them to avoid smoking and to limit intake of alcoholic beverages, caffeine, and sodium. Symptoms of HTN may become severe, with headache, fatigue, dyspnea, edema, and nocturia.
FIGURE 81-5 · Pressure and volume distribution in the systemic circulation. The graphs show the inverse relationship between internal pressure and volume in different portions of the circulatory system. Notice that the arterioles and the capillaries have decreased pressure as compared with pressure in the aorta. Arteries and arterioles are damaged by high pressures and, in turn, damage the organs that they service.
Malignant hypertension, which is not cancer, refers to a sudden onset of severely elevated blood pressure that is controllable. It is most often seen in young people. The incidence is highest in African Americans, especially men younger than 40 years. Onset is sudden, and the disease progresses rapidly. In many cases, determining its cause is difficult. Malignant hypertension is known to cause rapid necrosis (death) of vital organs, such as the heart, brain, and kidney. Clients with malignant hypertension rarely survive more than a few years.
Hypotension
Hypotension is low blood pressure. Clinical manifestations differ, depending on the underlying cause. Causes of hypotension can be classified under one of three mechanisms: a heart rate problem, a heart muscle or pump problem, or a volume problem. Treatment will depend on the underlying problem. Variations in blood pressure can also be caused by medications.
Rate problems include a heart rate that is too fast or too slow. Pump problems result from MI, cardiomyopathy (the heart cavity is enlarged and stretched), acute cardiac or aortic insufficiency, prosthetic valve dysfunction, cardiac tamponade (heart compression, caused by fluid buildup), pulmonary embolism, and medications that affect or alter the heart’s function. Many other clinical problems can also affect how the heart muscle pumps. Volume problems include hemorrhage, gastrointestinal fluid loss, renal injury or disease, central nervous system injury, spinal injury, sepsis, medications or disease processes that affect vascular tone, and any other condition that causes large-volume fluid losses.
