Question

Joey Jones, a 70-year-old male client, is scheduled tomorrow morning for a port access coronary artery bypass (PACAB) × 3 grafts. The procedure is also called a totally endoscopic coronary bypass (TECAB). The client has a history of osteoporosis so the surgeon felt that the minimally invasive procedure would be best because the breastbone would not have to be entered. The client has no history of smoking cigarettes. The surgeon has reviewed the cardiac angiogram results and a transesophageal echocardiogram (TEE) and stated he feels confident that the client’s lesions can be successfully bypassed using the PACAB approach. The client and wife need preoperative education from the LPN/LVN.

1.What preoperative instructions should the LPN/LVN provide the client/family?

2.What nursing management will the client need postoperatively?

Answer 1

Question no 1

Preoperative

Before surgery

In the 2 or 3 weeks prior to surgery, attend any scheduled appointments with your surgeon. You will need to have several tests done before your surgery. Most of these tests are done so that your doctors can evaluate and compare your health before and after CABG surgery. The tests can also help your doctors anticipate any special needs. To be ready by the day of your surgery, the tests need to be done days or weeks before.

Tests done days or weeks before surgery

Blood count (hematocrit): This blood test can reveal whether you are anemic (have a low red blood cell count). A very low blood count may need to be increased before or during surgery with a blood transfusion.

Prothrombin time (PT, also referred to as INR) and thromboplastin time (PTT) values: These blood tests measure your blood's ability to clot. Typically, you will have these tests if you have recently stopped taking blood-thinning drugs, to make sure the drugs are no longer affecting your blood's ability to clot.

Other blood tests: Other tests may be done to assess your kidney and liver functions and provide information on the health of these organs.

Chest X-ray: This test provides a picture of the size and shape of your heart and aorta and whether your lungs appear normal.

Cardiac catheterization: This test allows your doctor to picture your coronary arteries and identify the location of blockages to help plan your CABG surgery

emind the person who will drive you to the hospital what time you need to be there. It is important to arrive on time, as several preoperative tests and administrative tasks must be done.

Follow the instructions about exactly when to stop eating and drinking. If you don't, your surgery may be canceled. If your doctor has instructed you to take your medicines on the day of surgery, do so using only a sip of water.

Relax, but do not drink alcohol. It may dangerously interfere with medicines you will be given on the day of your surgery.

Use disinfecting solution (that your doctor may have given you) to clean your skin. This will minimize the risk of infection near your chest incision.

Select comfortable clothes to wear to and from the hospital. After the surgery, your wounds and muscles will still be sensitive, and comfortable clothing is less likely to irritate them.

Pack the bag that you will bring to the hospital. In general, hospital staff recommend that you pack lightly

Question no 2

Postoperative nursing mangement

The following aspects of postoperative care apply to all patients who've had CABG surgery.

• Maintain airway patency. Monitor the patients pul monary status closely and report any changes, such as pulmonary congestion, dyspnea, or Spo, below 92%. Follow the weaning protocol per orders. • Monitor vital signs and record intake and output hourly. Note the urine's color, clarity, and specific gray ity, Notify the surgeon of any signs of decreased renal perfusion

• Assess the patient's hemodynamic and cardiac status. Atrial fibrillation (AF) is a common complication of cardiac surgery, although its rarely life-threatening Treat persistent AF with medication or synchronized cardioversion as ordered.

• Perform peripheral and neurovascular assessments hourly for the first 8 hours. Then, if the patient is sta ble, perform these checks every 2 hours for the next 8 hours and every 4 hours for the following 8 hours, • Monitor his neurologic status and notify the surgeon and anesthesia provider if he hasn't awakened within 8 hours after surgery. Elderly patients and those with liver or kidney problems, history of stroke, or perfu sion deficits during surgery may need more time to recover from anesthesia