Coronary Artery Bypass Surgery

  1. General information
    1. A coronary artery bypass graft is the surgery of choice for clients with severe CAD.
    2. New supply of blood brought to diseased/occluded coronary artery by bypassing the obstruction with a graft that is attached to the aorta proximally and to the coronary artery distally.
    3. Several bypasses can be performed depending on the location and extent of the blockage.
    4. Procedure requires use of extracorporeal circulation (heart-lung machine, cardiopulmonary bypass)
  2. Nursing interventions: preoperative
    1. Explain anatomy of the heart, function of coronary arteries, effects of CAD
    2. Explain events of the day of surgery: length of time in surgery, length of time until able to see family.
    3. Orient to the critical and coronary care units and introduce to staff.
    4. Explain equipment to be used (monitors, hemodynamic procedures, ventilator, endotracheal tube, drainage tubes).
    5. Demonstrate activity and exercises (turning from side to side, dangling, sitting in a chair, ROM exercises for arms and legs, effective deep breathing, and coughing).
    6. Reassure client that pain medication is available.
  3. Nursing interventions: postoperative
    1. Maintain patent airway.
    2. Promote lung reexpansion.
      1. Monitor drainage from chest/mediastinal tubes, and check patency of chest drainage system.
      2. Assist client with turning, coughing, and deep breathing.
    3. Monitor cardiac status.
      1. Monitor vital signs and cardiac rhythm and report significant changes, particularly temperature elevation.
      2. Perform peripheral pulse checks.
      3. Carry out hemodynamic monitoring.
      4. Administer anticoagulants as ordered and monitor hematologic test results carefully.
    4. Maintain fluid and electrolyte balance.
      1. Maintain accurate I&O with hourly outputs; report if less than 30 ml/hour urine.
      2. Assess color, character, and specific gravity of urine.
      3. Daily weights.
      4. Assess lab values, particularly BUN, creatinine, sodium, and potassium levels.
    5. Maintain adequate cerebral circulation: frequent neuro checks.
    6. Provide pain relief.
      1. Administer narcotics cautiously and monitor effects.
      2. Assist with positioning for maximum comfort.
      3. Teach relaxation techniques.
    7. Prevent abdominal distension.
      1. Monitor nasogastric drainage and maintain patency of system.
      2. Assess for bowel sounds every 2-4 hours.
      3. Measure abdominal girths if necessary.
    8. Monitor for and prevent the following complications.
      1. Thrombophlebitis/pulmonary embolism
      2. Cardiac tamponade (see Cardiac Tamponade)
      3. Arrhythmias
        1. maintain continuous ECG monitoring and report changes.
        2. assess electrolyte levels daily and report significant changes, particularly potassium.
        3. administer antiarrhythmics as ordered.
      4. Congestive heart failure (see below)
    9. Provide client teaching and discharge planning concerning
      1. Limitation with progressive increase in activities
        1. encourage daily walking with gradual increase in distance weekly
        2. avoid heavy lifting and activities that require continuous arm movements (vacuuming, playing golf, bowling)
        3. avoid driving a car until physician permits
      2. Sexual intercourse: can usually be resumed by third or fourth week post-op; avoid sexual positions in which the client would be supporting weight
      3. Medical regimen: ensure client/family are aware of drugs, dosages, proper times of administration, and side effects
      4. Meal planning with prescribed modifications (decreased sodium, cholesterol, and possibly carbohydrates)
      5. Wound cleansing daily with mild soap and H2O and report signs of infection
      6. Symptoms to be reported: fever, dyspnea, chest pain with minimal exertion.