Module 5(Cardiac surgery)

What is endocarditis prophylaxis?

To reduce risk of prosthetic valve infected endocarditis Who -Artificial heart valve -History of bacterial endocarditis -Heart transplant with valve diseases When should antibiotic be given? -Dental procedures -Respiratory tract procedure -Manipulation of infected tissue What antibiotic is given? -Amoxicillin or clindamycin for people allergic to penicillin

When is valve repair or replacement commonly done?

With mitral valve disease than aortic valve disease Prosthetic valves can be either tissue or mechanical valve

What is aortic dissection?

**Not an aneurysm -It is a tear in the intima of the aorta that results in bleeding and formation of hematoma (Usually acute and life threatening) Risk: -Middle age men S/S: -Sudden tearing, sharp, knife like pain. -Pain radiates to back -10mmHG difference in BP in both arms Dx: -Transechocardio gram -CT -MRI Treatment: -Emergent surgical intervention (Patient is kept in bed in quiet environment) -BP kept low as possible -Pain and anxiety managed with meds

Nursing interventions for pos-op heart surgery?

-Achieve and maintain cardiac stability (90-14 systolic) (MAP 60-90) (Hypo or HTN) -Identify complications early -Promote effective gas exchange -Prevent post-operative delirium -Relieve pain -Rewarm without shivering -Patient and education

What are the types of arterial vascular disorders?

-Aortic aneurysm -Aortic dissection -Arterial embolism

What should be included in pre-op care for person experiencing heart surgery?

-Baseline functional status -Support system -Skin leisons? (inflammatory leison may indicate infection) -Reduce fear and anxiety -Focus on patient education and sensation

Why is the internal artery mammary graph?

-Because of long term patency (Vein grafts not as durable) (Most vein grafts within 10yrs of surgery)

What is coronary artery bypass grafting?

-Blood vessel is grafted to a coronary artery beyond an area of stenosis(detour)

What are some nursing diagnosis related to post op heart surgery?

-Decreased cardiac output -Impaired gas exchange (Extubate early ASAP) then techniques to improve breathing) -FE imbalance -Sensory disturbance -Acute pain -Impaired tissue perfusion -Ineffective thermoregulation -Self-care

Education for coronary artery bypass graft?

-Does not cure heart disease -Atherosclerosis will progress -Lifestyle modifications required

What should be included in post-op care for person experiencing heart surgery?

-Endotracheal tube placed (May require mechanical ventilation) -Central venous catheter may have been inserted for meds and fluids -Cardiac rhythm and Oxygen monitored continuously at bedside -Pulmonary artery cath used to measure body and pulmonary pressures -Radial artery cath used for blood sampling and fora arterial pressure -ECG and ABG obtained at intervals -Indwelling cath to monitor output

What are surgical complications from coronary artery bypass graft?

-Hypovolemia -Reduced contractility -Persistent bleeding -Cardiac tamponade -Dysrhythmias -Hypothermia -HTN -MI/heart failure (Chest tubes may be placed to drain blood) -tubes should be stripped as this exerts too much -pressure -too much bleeding is more than 500ml in 24hr 200ml in every hr after

What is an aortic aneurysm?

-Is a permanent out pouching of the aorta -Abdominal aortic aneurysm(below renal artery is most common type) Risk factors -Atherscleosis -Genetic -Men -Age over 65 -Smokers S/S: Initial: Asymptomatic -Chest pain when patient lying down -Dyspnea -Difficulty swallowing -Hoarseness -Sometimes abdominal bruing Dx: -PE and X-ray -Ultrasound (the larger the aneurysm the greater the risk of rupture) Treatment: -Surgical repair for larger than 6cm or expanding rapidly

What is ballon valvuplasty?

-Is catheter based procedure used for mitral stenosis -More recently used in people with aortic stenosis who can not undergo open heart surgery due to advanced age

Which valves are priority for cardiac fucntion?

-Mitral and aortic valve

Nursing interventions for aortic aneurysm?

-Monitor graphy patency\renal perfusion -Monitor for hematoma at catheter insertion site -Monitor BP (prolonged hypotension=thrombosis) (prolonged HTN=disrupt the suture line) -Pulses should be checked regularly and recored -Record output

Post operatively what systems should be assessed?

-Neuro -Respiratory -Cardiac -Renal Nurse should also assess equipment along with monitoring IV fluids and medications

What is the collaborative management for VHD?

-Prevention of VHD and endocarditis(infection of endothelial cells of heart) -Infection of right heart valve frequent(especially in IV drug users) -Asymptomatic stage Period of watchful waiting Patients will be evaluated with ECHO Patient will be educated endocarditis prophylaxis for (prostetic cardiac valves, past history, congential heart disease) Questions of antibiotics -Symptomatic stage Timing of surgical intervention is critical Either valve repair or valve replacement Require life long care (Palliative not curative)

In general what is stenosis?insuffiency?

-Prevents valve from opening fully -Prevents valve from closing all the way When not closed all the way leaks across the valve-regurgitation **when blood is stenotic or insufficient=turbulent blood flow

What is an arterial embolism?

-Sudden interruption of blood flow by clot or piece of plaque Risk factor -A-fib -Mitral stenosis -Endocarditis -Smoking S/S: -Pain -Pallor -Pulselessness -Parestesia -Paralysis -Prokilothermia(cool) (Onset is sudden unless imposed on chronic PVD) Treatment: (Early needed to preserve limb) -Anticoagulation (unfractured heparin) therapy with continuous IV is started immediately -If person is stable after heparin embolism may be removed with catheter -Surgical arrteriotomy Complications -MI -Stroke -Kidney injury (if blood flow not reestablished patient is at risk for loss of limb)

What are types of aortic valve disease?

Aortic stenosis -May result from rheumatic fever or calcification of age related change in leaflets -Obstruction of blood flow from LV to aorta -Loud, rough systolic murmur at base -S/S/; Asymptomatic or hypertrophy of left ventricular cells -As disease progresses can produce angina and HF (Would not give nitroglycerin to treat angina cuz vasodilator would reduce pre-load) --Pre-load needed to open valve -May describe weakness and SOB Aortic regurgitation -Blood flows back into LV from aorta -May result from disease and degeneration of aortic valve leaflets -S/S: transient chest pain and shock -High-pitched, blowing, diastolic murmur at base -Acute regurgitation may result form endocarditis, infection, trauma(life threatening) -Chronic result from rheumatic fever -People who have it severe have collapsing type pulse

What are the types of valvular heart disease?

Aortic stenosis Aortic insufficiency Mitral regurgitation Mitral stenosis

What is the general appearance of the patient?

Cool cold puffy and nursing support essential

Before surgery what has to happen?

ECHO -to evaluate valvular structure Nuclear scan -to evaluate cardiac muscle viability Cardiac catheterization -to find areas of blockage and locate target vellses

What are types of mitral valve disease?

Mitral valve prolapse -Structural abnormality of the leaflet -Mitral valve balloons back into left atrium via left ventricular contraction -Most common valve disorder in U.S -Usually benign but cardio endocarditis and mitral regurgitation can develop Mitral regurgitation -Back flow of blood into the left atrium during left ventricular contraction -Produces systolic murmur based placed at apex of the heart (high pitch, blowing) -If develops slowly may asymptomatic -Dyspnea on exertion if condition worsens Mitral stenosis -Obstruction of blood flow from LA to LV -Low-pitched, rumbling, diastolic murmur at apex -S/S: Dyspnea on exertion, weakness, fatigue ***in developing countries rheuamtic fever most common cause for mitral valve disease

What are post-op nursing considerations for valve repair or replacement?

Monitor -FVE -Decreased CO -Knowledge deficit Goals -Achieve hemodynamic stability -Prevent complications Dysrhythmia FE imbalance Anti-coagulation (Long term Recommended for patients with mechanical valve) --Short term 2-3months Endocarditis prophylaxis

What is the treatment for aortic aneurysm?

Once discovered it is monitored every 6 months Increase rupture or death in aneurysm greater than 5cm Signs of severe rupture include back or abdominal pain Signs of actual rupture -Intense pain -Falling BP -Falling HCT Treatment -Surgery (open vascular repair if patient stable) (Requires cross clamping proximal/distal) (Can be completed in 30-40min) Minimally invasive (Placement of suture-less aortic graph)into abdominal aorta into aneurysm via femoral artery) ---then impacted against aortic wall by ballon inflation

What are the types of coronary artery bypass?

Traditional -General anesthesia -Incision is made in center of the sternum -Heparin used to prevent clotting and and blood is cooled Alternative CABG techniques -Off-pump CABG (Surgery performed on beating heart) -Minimally invasive techniques