Question

Case Study:

Mr S. is a 45-year-old man who has just been admitted to the ICU postoperative cardiac surgery. He has had an uneventful coronary artery bypass graft with no complications in the operating room. He is intubated and placed on complete mechanical ventilation. His vital signs are: blood pressure (BP) 150/90 mm Hg, heart rate 86 beats per minute, respiratory rate 12 breaths per minute, and temperature 35.3°C

The target systolic BP for Mr S. is less than 130 mm Hg and the surgeon’s postoperative orders include BP medications and intravenous morphine sulfate for pain. In addition, the surgeon prescribes an nonsteroidal anti-inflammatory drug, ketorolac, to be administered to the patient once it has been determined that they are not bleeding excessively and have acceptable renal function.

The ICU where Mr S. is admitted has a respiratory therapist (RT) on staff. This RT is aware that mechanical ventilation is very uncomfortable for patients. There is a standing order in the ICU that heart surgery patients may be weaned from the ventilator as tolerated and extubated when stable.

When Mr S. is beginning to arouse from the anesthesia, he is grimacing and his BP is rising above the target level. The nurse administers morphine sulfate as ordered. In addition, Mr S. is given a warming blanket to increase his body temperature.

The next morning, Mr S. is seen by the ICU physiotherapist. When assessing Mr S.’s comfort needs, the physiotherapist recognizes that he is anxious about moving and exercising so soon after surgery. With this in mind, the physiotherapist carefully explains her plan of care to Mr S. in a calm and unhurried manner. This allows Mr S. to relax. He becomes willing and able to work with the physiotherapist in his postoperative exercise routine.

The healthcare team worked collaboratively to enhance the patient’s comfort during the immediate postoperative period. This, in turn, led to Mr S. having a successful recovery period with no significant complication.

1. What will be the best action of the nurse together with other members of the health team in the dance of caring process?

2. How would you promote to the maximum level of health of Mr. S considering his present condition . How could you increase his self efficacy in performing activities when he is discharge from the hospital?

Answer 1

A. Nurse and physician will help in these things:-

1. Stay active - Some level of physical fitness helps counteract the immobility of recovery.

2. Quit smoking- Not smoking before and after the operation reduces the odds of developing pneumonia or other complication.

3. Don't diet- When the body is under stress, it tends to break down muscle. Healing requires calories, especially from protein. Long-term changes in diet may be needed later, but a healthful diet helps recovery.

4. Keep a positive attitude- Some people become depressed after bypass surgery. A positive attitude can influence how quickly you become active again.

5. Take medications as prescribed- Bypass surgery may restore blood flow to the heart muscle, but the disease that caused the blockage is still there. Taking medications as prescribed helps avoid the need for another bypass surgery down the road.


B. Advice patient to promote his condition-

•DO NOT stand or sit in the same spot for too long.
•Walking is a good exercise for the lungs and heart after surgery.
•Climbing stairs is OK, but be careful.
•Light household chores, such as setting the table, folding clothes, walking, and climbing stairs, should be OK.

Advice during discharge-

▪Do the breathing exercises you learned in the hospital for 4 to 6 weeks.

▪Shower every day, washing the incision gently with soap and water. DO NOT swim, soak in a hot tub, or take baths until your incision is completely healed. Follow a heart-healthy diet.

▪If you feel depressed, talk with your family and friends. Ask your health care provider about getting help from a counselor.

▪Continue to take all your medicines for your heart, diabetes, high blood pressure, or any other conditions you have.

▪DO NOT stop taking any medicine without first talking with your provider.Your provider may recommend antiplatelet (blood-thinning) drugs such as aspirin, clopidogrel (Plavix), prasugrel (Effient), or ticagrelor (Brilinta) to help keep your artery graft open.If you are taking a blood thinner, such as warfarin (Coumadin), you may need to have extra blood tests to make sure your dose is correct.