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U world cardiac 2

Home Care Instructions for the Client After Cardiac Surgery

▪ Progressive return to activities at home

▪ Limiting of pushing or pulling activities for 6 weeks following discharge

▪ Maintenance of incisional care and recording signs of redness, swelling, or

drainage

▪ Sternotomy incision heals in about 6 to 8 weeks

▪ Avoidance of crossing legs; wearing elastic hose as prescribed until edema

subsides, and elevating the surgical limb (if used to obtain the graft) when

sitting in a chair

▪ Use of prescribed medications

▪ Dietary measures, including the avoidance of saturated fats and cholesterol and

the use of salt

▪ Resumption of sexual intercourse on the advice of the primary health care

provider or cardiologist after exercise tolerance is assessed (usually, if the client

can walk 1 block or climb 2 flights of stairs without symptoms, she or he can

resume sexual activity safely).

1. Description

a. The occluded coronary arteries are

bypassed with the client’s own venous

or arterial blood vessels.

b. The saphenous vein, internal mammary

artery, or other arteries may be used to

bypass lesions in the coronary arteries.

c. Coronary artery bypass grafting is

performed when the client does not

respond to medical management of

coronary artery disease or when

vessels are severely occluded.

d. A minimally invasive direct coronary

artery bypass (MIDCAB) may be an

option for some clients who have a

lesion in the LAD artery; a sternal

incision is not required (usually a 2-

inch [5-cm] left thoracotomy incision is

done), and cardiopulmonary bypass is

not required in this procedure.

2. Preoperative interventions

a. Familiarize the client and family with

the cardiac surgical critical care unit.

b. Inform the client to expect a sternal

incision, possible arm or leg incision(s),

1 or 2 chest tubes, a Foley catheter, and

several IV fluid catheters.

c. Inform the client that an endotracheal

tube will be in place for a short period

of time and that she or he will be

unable to speak.

d. Advise the client that she or he will be

on mechanical ventilation and to

breathe with the ventilator and not

fight it.

e. Instruct the client that postoperative

pain is expected and that pain

medication will be available.

f. Instruct the client in how to splint the

chest incision, cough and deep breathe,

use the incentive spirometer, and

perform arm and leg exercises.

g. Encourage the client and family to

discuss anxieties and fears related to

surgery.

h. Note that prescribed medications may

be discontinued preoperatively

(usually, diuretics 2 to 3 days before

surgery, digoxin 12 hours before

surgery, and aspirin and

anticoagulants 1 week before surgery).

i. Administer medications as prescribed,

which may include potassium

chloride, antihypertensives,

antidysrhythmics, and antibiotics.

3. Cardiac surgical unit postoperative interventions

a. Mechanical ventilation is maintained

for 6 to 24 hours as prescribed.

b. The heart rate and rhythm, pulmonary

artery and arterial pressures, urinary

output, and neurological status are

monitored closely.

c. Mediastinal and pleural chest tubes to

the water seal drainage system with

prescribed suction are present;

drainage exceeding 100 to 150 mL/hr is

reported to the PHCP.

d. Epicardial pacing wires are covered

with sterile caps or connected to a

temporary pacemaker generator; all

equipment in use must be properly

grounded to prevent microshock.

e. Fluid and electrolyte balance is

monitored closely; fluids are usually

restricted to 1500 to 2000 mL, because

the client usually has edema.

f. The blood pressure is monitored

closely, because hypotension can cause

collapse of a vein graft; hypertension

can cause increased pressure,

promoting leakage from the suture

line, causing bleeding.

g. Temperature is monitored and

rewarming procedures are initiated

using warm or thermal blankets if the

temperature drops below 96.8° F

(36.0° C); rewarm the client no faster

than 1.8 degrees/hr to prevent

shivering, and discontinue rewarming

procedures when the temperature

approaches 98.6° F (37.0° C).

Alpha-glucosidase inhibitors Oral hypoglycemic. Acarbose (Precose) and miglitol (Glyset). Slows carbohydrate absorption and digestion. Contraindicated in clients with intestinal disease due to increased gas formation.

Biguanides Oral hypoglycemic. Metformin (Glucophage). Reduces gluconeogenesis and increases uptake of glucose by muscles. Withhold 48 hours prior to and 48 hours after a test with contrast media. Contraindicated in clients with severe infection, shock, and hypoxic conditions.

Gliptins Oral hypoglycemic. Sitagliptin (Januvia). Promotes release of insulin, lowers glucagon secretion and slows gastric emptying. Caution with impaired renal function- dose will be reduced.

Meglitinides Oral hypoglycemic. Repaglinide (Prandin) and nateglinide (Starlix). Reduces production of glucose within the liver through suppression of gluconeogenesis. Increases muscle uptake and use of glucose. Should not be used with NPH insulin due to risk of angina.

Sulfonyleureas Oral hypoglycemic. Glipizide (Glucotrol) and glyburide (DiaBeta, Micronase). Promotes release of insulin from the pancreas. Extreme high risk of hypoglycemia in clients with renal, hepatic, or adrenal disorders.

Thiazolidinediones Oral hypoglycemic. Rosiglitazone (Avandia) and pioglitazone (Actos). Decreases insulin resistance. There is high risk of CHF due to fluid retention.

Oral Hypoglycemic Nursing Interventions Teach signs and management of hypoglycemia, especially with sulfonylureas. Encourage diet and exercise to follow American Diabetes Association recommendations. Monitor glycosylated hemoglobin (HbA1C). Refer to diabetic nurse educator.

Lispro (Humalog) Rapid-acting insulin. Onset: less than 15 minutes. Peak: 0.5-1 hour. Duration: 3-4 hours.

Regular (Humulin R) Short-acting insulin. Onset: .5-1 hour. Peak: 2-3 hours. Duration: 5-7 hours.

NPH (Humulin N) Intermediate-acting insulin. Onset: 1-2 hours. Peak: 4-12 hours. Duration: 18-24 hours.

Insulin glargine (Lantus) Long-acting insulin. Onset: 1 hour. Peak: none. Duration 10.5 to 24 hours.

Insulin Therapeutic Uses Glycemic control of diabetes mellitus (1, 2, gestational) to prevent complications. Clients taking oral hypoglycemic agents may require insulin therapy when: undergoing diagnostic tests, pregnant, severe kidney or liver disease is present, oral agents are insufficient, and treatment of hyperkalemia. Risk for hypoglycemia/hyperglycemia and lipodystrophy.

Insulin Precautions/Interactions When mixing regular with NPH insulin, draw up regular first. Do not mix other insulins with lispro, glargine, or combination 70/30. Only regular insulin is given IV (only in normal saline). Administer glargine at bedtime.

Insulin Nursing Interventions and Client Education Monitor serum glucose levels before meals and at bedtime or patterned schedule-specific to client. Roll vial of insulin (except regular) to mix, do not shake. Instruct client to rotate injection sites to prevent lipodystrophy. Teach signs and management of hypo/hyperglycemia. Encourage diet and exercise to follow ADA recommendations. Monitor glycosylated hemoglobin (HbA1C). Refer to diabetic nurse educator.

Glucagon (GlucaGen) Glycemic Agent. Initiates regulatory processes to promote breakdown of glycogen to glucose in liver, resulting in increased serum glucose levels. Emergency treatment of severe hypoglycemia. Do not mix with sodium chloride or dextrose solutions. Side effects are nausea and vomiting and rebound hypoglycemia.

Glucagon Nursing Interventions Administer medication for unresponsive client, monitor blood glucose levels, instruct client to self-monitor for early signs of hypoglycemia, instruct client to wear medical alert ID, advice client to teach family members how to administer medication, provide carbohydrates when client awakens from hypoglycemic reaction.

Levothyroxine/T4 (Synthroid) Thyroid hormone. Stimulates metabolism of all body systems by accelerating the rate of cellular oxygenation. Used for hypothyroidism and emergency treatment of myxedema coma. Overmedication can result in signs of hyperthyroidism.

Side effects of Synthroid Tachycardia, restlessness, diarrhea, weight loss, decreased bone density, heat intolerance, and insomnia.

Synthroid Nursing Interventions Monitor cardiac system, therapy initiated with low doses, advance to higher dosages while monitoring lab values, monitor T4 and TSH levels, take it early in the morning.

Methimazole (Tapazole) Thyroid hormone antagonist. Inhibits synthesis of thyroid hormone. Used for hyperthyroidism, preoperative thyroidectomy, thyrotoxic crisis, and thyroid storm.

Tapazole Precautions/Interactions Administer with caution to clients who have bone marrow depression, hepatic disease, or bleeding disorders. Discontinue prior to radioactive iodine uptake testing. Contraindicated with breastfeeding.

Tapazole side effects Skin rash, pruritus, abnormal hair loss, GI upset, paresthesias, periorbital edema, join and muscle pain, jaundice, agranulocytosis, and thrombocytopenia.

Tapazole Nursing Interventions Administer with food at the same time each day, increase fluids to 3 L/day, instruct client to avoid OTC products containing iodine, instruct client to take medication as prescribed, if discontinuing dose must be tapered off, monitor client for therapeutic response: weight gain, decreased pulse, BP, and T4 levels, monitor client for signs of overdose: periorbital edema, cold intolerance, mental depression.