Coronary Artery Bypass Graft (CABG): Introduction and Pre-procedure Nursing Care

00:01 Hi, I'm Professor Laws and I have waited forever to get to do this video for you.

00:05 So I'm so glad you're joining us today.

00:07 When I first started as a baby nurse, these were the nurses that I was just in awe of, the nurses that took care of the cabg patients, the people who had had a coronary artery bypass graft, you know, the kind of where they split their chest open and they take a piece of vein from one place and they make a new connection.

00:27 I mean, those patients only the rock star nurses got to take care of them.

00:32 Now, we've gotten way better at the surgery now these days, but there's still a lot of complex procedures that they're going to need very precise care at every stage.

00:40 And so today, I'm going to talk about the specific nursing interventions that these clients need before, during and after surgery.

00:47 So to help us organize this and because I know you're going to take the NCLEX one day, we're going to organize it between the clinical judgment measurement model.

00:56 It's the same framework that they use on the NCLEX exam, the part you're going to care about is that I'm going to teach you the cues to look for how to put those cues together and make your own hypothesis.

01:07 Those are the first three steps.

01:09 Memorizing interventions is a part of nursing school.

01:12 However, I always want you to remember that patients are human beings and their care has to be individualized.

01:19 So as we're moving through the content, I'm going to share examples of how you might need to individualize your approach to meet each patient's unique needs.

01:26 Now, although a majority of these interventions are consistent between healthcare organizations, you might notice some small differences in the hospitals that you go to. So it might be in the order of how things are done or additional interventions with different populations or surgeon preferences.

01:41 Just keep that in mind.

01:43 There is much more than one way to take care of a cabg patient.

01:48 So let's start with the beginning.

01:49 We're going to talk about what you would do pre-procedure before the patient has the cabg.

01:54 So before we do the nursing interventions, let's go back and make sure you're really clear on what a coronary artery bypass graft surgery involves.

02:02 So in a coronary artery bypass surgery, the surgeon this is so cool.

02:07 The surgeon removes a piece of blood vessels from the leg, the chest, the arm, the trunk.

02:12 And then the surgeon uses that piece of blood vessel.

02:15 They call that a graft to reroute the blood around the blocked artery.

02:20 That is incredible.

02:21 The surgery is called bypass surgery because it bypasses the blockage.

02:26 Now, the first of a series of interventions is based on your ability to recognize important cues.

02:32 So seeing what is important relies on our assessment ability.

02:35 So keep in mind, the nurse is constantly assessing and reassessing the situation as things change. And with cabg patients, wow, things can change in a literal heartbeat.

02:46 Just like everything else.

02:47 You start with a complete patient history.

02:50 So let's talk through this like we really were taking care of a patient, so we get the patient history, we do a cardiovascular-focused physical exam, we look at the whole patient. But because of what they're having done, you really want to do an in-depth, cardiovascular-focused physical exam.

03:07 You want to look at lab results.

03:08 So you look at like the patient's CVC and their electrolytes.

03:12 Also, you look through their history and you would note that, Hey, wait a minute, this patient has a history of heart disease and lung disease, so you make sure you check out their lungs. They're clear, but they are somewhat diminished in the bases.

03:26 So you're starting to form a picture.

03:28 You have a patient. We've done the history, we've done the assessment.

03:31 We know that they have a history of heart and lung disease and their lungs are clear, but they're a little bit diminished in the bases.

03:38 So what do you do if the patient appears anxious, tells you that one of their parents also had this procedure and they didn't survive? Well, this information is critical to you deciding what the priorities are moving forward. So you have the physical, but you also have what the patient is communicating to you. They're anxious because they had a relative that had the same procedure and they didn't survive before any procedure.

04:01 We always assess the patient.

04:03 Now, with this particular example, we've looked at lots of physical assessment.

04:07 We've also talked to them, asked them about their history.

04:10 These are the things we're going to put together to analyze the cues that's going to help us prioritize and come up with what we think is the most important for this patient.

04:20 What do they require from us as a nurse to help them have the most safe and effective care? So based on the assessment of this patient, their lab work and a physical exam was within expected ranges.

04:32 Now we might choose to prioritize some other needs because of our interaction with this patient. We know that all patients are at risk for infection that have surgery, right? They may also have knowledge deficits.

04:43 Those are things that are pretty universal for somebody undergoing a surgical procedure.

04:48 But this third one I want to talk to you about is specific and individualized to this patient. What about anxiety this patient shared with us, Hey, I have a personal history of a family member having a very negative outcome with this same procedure.

05:03 See, it's going to take you thinking critically about how you're going to provide the most safe and effective care for this client.

05:11 And remember, individualizing a patient's care is critically important.

05:16 Okay. So now that we have a grasp of what will or could happen, that could be a hypothesis, right? We prioritize that.

05:23 So we need to make these priorities to guide us in how we generate solutions to our hypothesis that will tell us what specific actions we need to implement.

05:34 Okay, take a breath.

05:35 That is a lot of information for you to process.

05:39 Let me tell you how this will help you on your exams.

05:43 When you recognize cues in the stem of a question, you analyze them.

05:47 You make your hypothesis in what is going on and what you need to do.

05:52 This will help you generate solutions and prioritize, which is the most correct answer on the question.

06:00 Now, through the test in there, because I know everyone worries about test, but in care we do the same thing.

06:06 What's going on with this patient? What are the cues I'm looking for when I analyze them, put them together? What are the biggest needs now? I need to act on those needs.

06:14 So for this patient, educating him about the procedure, teaching deep breathing exercises because we don't want them to develop pneumonia and they're going to be kind of uncomfortable after the surgery.

06:24 So they'll be hesitant to take a deep breath.

06:27 We'll make sure they don't eat anything before the surgery.

06:30 They're NPO, nothing by mouth, and we'll make sure the surgical site is prepared.

06:35 The paperwork that is unique to that hospital is all completed according to the guidelines.

06:40 So they're ready to go for the procedure.

06:43 So back to this patient.

06:45 Remember, they reported a history of lung disease.

06:48 Now, this was during the admission assessment that you did.

06:50 You also noted clear but diminished lung sounds in the bases.

06:54 So while everyone needs to be taught deep breathing exercises and likely use an incentive spirometer, this patient is particularly at risk to develop a complication. So we want to take additional steps to ensure they understand why it's important for them to take deep breaths and to use their incentive spirometer.

07:12 Now, I know as you're a nursing student, you already know if that patient doesn't take those deep breaths, they're at risk of developing a pneumonia.

07:20 So this is how you get to carry out, like the right interventions, the things that are for the most safe and effective care.

07:26 And a lot of places will have standardized care plans.

07:28 It'll be set by the agency.

07:30 This is what we do for all patients having this procedure or this diagnosis.

07:34 And it will be based on evidence-based guidelines.

07:37 So another part of standardized plans of care before somebody goes for surgery is obtaining informed consent.

07:43 Now, on informed consent, you are the witness to that.

07:47 You are not the person who is responsible for explaining the procedure to the level that the patient signs informed consent.

07:54 So remember that that's up to the health care provider doing the procedure.

07:58 So routine steps obtaining informed consent by signing and being a witness, administering the pre-op medications as ordered by the health care provider.

08:06 And then you'll be collaborating with the surgical team about the right patient right side steps.

08:12 Now, if you haven't heard about that, we are extremely conscientious about making sure that we're doing the right procedure on the right patient, even for things like which side of the body needs to be operated on.

08:25 Et cetera. For this one, it's going to be a cabg.

08:27 But on every surgical procedure, I am just as responsible as the surgical team for making sure I discuss and communicate.

08:36 Right. Patient right side steps.

08:39 Now remember the anxiety.

08:40 Remember the patient showed us they were kind of anxious because they shared that they had a family member who died after this procedure.

08:46 So maybe they would benefit from some extra time for them to share their story.

08:51 Maybe they want to just have you listen to what they're experiencing, what's got them most concerned.

08:57 Make sure that you're patient and you sit down, make eye contact with the patient and answer all of their questions, provide them reassurance, but make sure it's not false reassurance. Be very careful about the words that you choose to use.

09:12 You want to say things like, your healthcare team will do everything they can to keep you as safe as possible.

09:18 Don't make promises that we can't absolutely deliver, so be very careful with your choice of words. Last but not least, you and I, the nurse.

09:28 We're constantly evaluating the effectiveness of the choices we made based on our assessment. Now, when you're thinking about someone having a coronary artery bypass graft, there are some specific pre-procedural concerns.

09:41 Remember, this is where you stop.

09:43 Take a deep breath and look at whether or not all these interventions were done on the right patient in the right sequence and for the right reason.

09:52 Now, because of what we know about this patient, we're going to pay extra attention to the teach back portion of the education you provide about the procedure.

10:01 We want the patient to be very clear about what to expect after the procedure, and we're going to watch extra carefully to make sure the patient can use the incentive spirometer.

10:11 Why we were worried about those diminished lung sounds in the bases.

10:16 So in addition to the interventions to reduce infection risk and ensure knowledge gained by the patient, you are working to decrease pre-surgical anxiety.