NURSING: The Postoperative Phase
Postoperative care of the cardiac surgery patient is challenging in that changes can occur rapidly. The preoperative condition of the patient as well as intraoperative events should be considered in postoperative care. It is essential for the nurse to anticipate the possible complications so that appropriate interventions are initiated in a timely manner in order to ensure a positive outcome for the patient.
There is a flurry of activity as the patient enters the recovery room/ICU and the admitting nurse connects the patient and the invasive lines to the monitoring equipment while another staff member connects drainage devices appropriately and draws admission blood work. The operating room nurse and the anesthesiologist report the patient's condition to the receiving nurse.
Postoperative Pulmonary Management
Pulmonary dysfunction and hypoxemia may occur in 30% to 60% of patients after CABG.10 Patient history and intraoperative factors must be considered in the postoperative pulmonary management. A history of smoking, obstructive pulmonary disease, steroid use, gastroesophageal reflux disease, heart failure, and poor nutrition may increase postoperative pulmonary complications.11
Although there are some variations to this protocol, most patients will be intubated and mechanically ventilated upon arrival in the recovery room. Desired outcomes include adequate oxygenation and ventilation while the patient is intubated. Early extubation isalso a desired outcome as long as the patient is hemodynamically and neurologically stable. There is potential for an increase in postoperative complications when patients are intubated longer than 24 hours. The length of hospital stay may also increase with longer intubation times.12 The current trend is to extubate patients within the first 12 hours after surgery. On occasion, patients may be extubated in the operating room. Routine postoperative care to promote oxygenation and ventilation involves prevention and treatment of atelectasis and pulmonary infection as well as maintenance of effective gas exchange and breathing patterns.
There are several factors during heart surgery that increase the potential for pulmonary complications postoperatively. The length of the surgery and resultant increase in the amount of needed anesthetic agents, the amount of fluids administered during the intraoperative period, and prolonged time in the supine position increase the potential for pulmonary complications. Atelectasis can be related to cardiopulmonary bypass, surfactant inhibition, and stimulation of the inflammatory response.9 Atelectasis, as well as the inflammatory mediators, inhibits diffusion of oxygen and carbon dioxide across the alveolar capillary membrane and impairs effective gas exchange. Prolonged pump time causes fluid shifts, potentially increasing the amount of fluid in the pulmonary tissue, thus increasing the possibility of pulmonary complications. Pain caused from the sternotomy can impair breathing patterns. Some patients shiver after heart surgery and this response may lead to an increase in the carbon dioxide level or lead to lactic acidosis. Shivering may increase the body's oxygen consumption, therefore, oxygen levels should be monitored and adjusted accordingly. Shivering may be the result of the body compensating for the surgically induced hypothermia or a reaction to anesthetic agents. Shivering is usually managed by administration of sedation and neuromuscular blocking agents while the patient is being mechanically ventilated.
Postoperative management includes accurate and frequent physical assessment, arterial blood gas analysis, continuous pulse oximetry, pulmonary care (including suctioning while the patient is intubated and coughing and incentive spirometry after extubation), early mobilization, and control of pain and shivering. Most protocols require a chest x-ray after heart surgery to determine placement of...
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