Coronary Artery Bypass Graft (CABG): Operative and Post-procedure Nursing Care

00:01 Earlier we discussed pre procedure management for a patient having a coronary artery bypass graft. Now we're going to talk about your role during the procedure.

00:10 Now, we all know that nurses are constantly assessing and reassessing as the patient care situations change or the patient's status changes.

00:18 This is what helps us recognize important cues so we know how to prioritize our care.

00:23 Now, keep in mind that the steps may be different depending on what role you have.

00:29 Now, it can depend on a couple of things.

00:30 What about your organization? You might be the nurse completing the pre-procedural inventions, but you may not be the nurse assigned to the care during the procedure.

00:38 So just keep in mind we're giving you an overview of the roles of nurses for patients having a cabg.

00:45 Either way, the nurse assigned to the patient in the operating room has the primary responsibility to work with the surgical team to continuously evaluate physiological stability. Now, in order to do this, we have some pretty unique tools in the or C hemodynamics are assessed through both noninvasive things you would recognize and invasive measures.

01:06 With these tools, we're looking at blood pressure and pulse pressure, the heart and respiratory rate, peripheral and arterial oxygen saturation.

01:14 These are all measurements that will give us early indication if the patient is declining.

01:19 Now, the intra-arterial axis gives us instantaneous information.

01:24 That way we can see what do we need to do to titrate the various medications, the IV fluids and the respiratory support that's being administered throughout the procedure.

01:35 So let's consider if our patient shows symptoms of cardiac instability during the intraoperative period.

01:41 So during the procedure, this could look like something like irregular heartbeats, fluctuations of blood pressure and widening pulse pressure.

01:49 So you see those cues.

01:51 You would next analyze those cues because by analyzing those cues, it will allow us to determine our priority hypothesis.

01:58 Okay. So when the nurse analyzes a cue and determines that the patient assessment information is outside of the expected range, the nurse is prioritizing the abnormal finding. Now pause for a minute and think back what were at least three examples that we just discussed about things that might look out of the normal or expected range during the procedure. Don't look at your notes.

02:23 Try and see if you can recall on your own.

02:28 Irregular heartbeats or dysrhythmias, their blood pressure could be fluctuating or their pulse pressures might be widening.

02:35 Now, whenever we notice is out of range, that's what sets our priority.

02:41 Because the nurse is the patient advocate.

02:43 The nurse in this situation is likely to generate the solution of signaling a need for intervention because, you know, the nurse is in a position to take action by anticipating the need for more or different types of fluids, different medications or equipment to assist the surgical team to correct the symptoms of hemodynamic instability.

03:02 Now, as the situation evolves, the nurse evaluates the effectiveness of these care changes and the whole cycle begins again of clinical judgment.

03:12 Now, throughout a complex surgical procedure like a cabg, the nurse applies the clinical judgment nursing measurement model framework to both standard care and unexpected shifts in the patient assessment data.

03:24 Typically, the most important aspect of nursing care in the intraoperative period is being ready to act on both nursing and surgical training to assist the surgical team as needed. Now, this could include instrument handling and maintaining a sterile environment throughout the procedure.

03:39 The nurse manages IV lines.

03:41 They give fluids and medications, but also lines, tubes and drains that help keep the patient safe and provide patient assessment information.

03:51 Now the nurse will communicate the data about these lines, tubes and drains with the surgical team throughout the entire procedure.

03:57 Now, each piece of the assessment data, each action and reaction is being evaluated for effectiveness because these evaluations allow the nurse to individualize the care to meet the patient where they're at.

04:08 So if you choose to be the nurse who's in the room where it happens, your role include collaboratively monitoring the patient's physiological status and ensuring the safe and effective use of surgical and monitoring equipment after the procedure, which in this case was a coronary artery bypass graft.

04:25 The nurse providing post-operative care has the primary responsibility to assess and reassess. Keep that in mind.

04:33 So you're going to assess and reassess the patient for cues.

04:36 You're looking for cues of hemodynamic, respiratory and cognitive stability.

04:42 Now, most patients recover from these procedures on an expected trajectory as anesthesia wears off and the body begins to heal.

04:49 Post-operative care guidelines will include directions on the frequency of assessment, the analysis of cues and vital signs.

04:56 You'll be collecting urinary and chest tube and nasogastric tube outputs, as well as level of orientation signs or symptoms of infection and pain levels to see if they are within the expected or unexpected ranges.

05:10 The nurse will also regularly assess the condition of the sites of entry of each of the various tubes, lines and drains.

05:17 They're going to want to make sure that they are patent and they don't show any signs or symptoms of infection.

05:22 Now, there could also be multiple incisional dressing sites, so you're going to want to monitor those for bleeding or signs and symptoms of infection.

05:30 Now, the patient can have a traditional sternal incision or a lateral intra-rib access in addition to wherever the veins were harvested.

05:38 This can be on any of the extremities.

05:41 During the post-operative care period.

05:43 The nurse continuously analyzes all of these pieces of assessment data.

05:48 This critical thinking is when prioritization of hypotheses happens and where the nurse considers what actions are within the nursing scope of practice and which actions require other members of the interdisciplinary team.

06:00 Now, there are many hypotheses for the nurse to apply to care for a post-operative cabg patient. Let me give you some examples.

06:06 These would include patient safety, hemodynamic and respiratory stability, potential for bleeding or infection, pain management and psychological support for both the patient and the loved ones.

06:19 Okay, so when you're caring for a patient who's had a cabg, look at those five areas.

06:25 You want to be thinking through those and assessing how the patient is doing in each of these areas and reassessing what's most important that you provide for them.

06:34 Depending on the unique patient priority hypothesis may be different or constantly shifting. So let's walk through this with this patient.

06:42 Let's start with the nurse performing a standard post-operative assessment one day after the cabg procedure on the post-surgical care unit.

06:49 Now the nurse finds the patient fully awake with vital signs.

06:53 Level of orientation, intake and output are all within expected ranges.

06:57 Now, during this comprehensive assessment, those are the kind of cues you like to find.

07:01 We know the patient is currently safe.

07:03 Hemodynamically stable shows no signs and symptoms of infection and the pain is being managed. So after taking this information in, the nurse, based on the analysis of these cues, determines a priority hypothesis.

07:18 A hypothesis we're going to implement the standard post-operative nursing action.

07:24 What is that action? Assisting the patient to get out of bed and sit in a chair for the first time.

07:31 Hey, if you've just had this surgery, this is a big deal.

07:35 So we as the nurses, we generate solutions because we're anticipating what actions will need to be taken for this procedure.

07:42 In this case, assisting the patient to get out of bed and sit in the chair for the first time. I want to talk you through some things that you would normally think through.

07:51 We won't cover everything, but I just want to give you some examples.

07:54 So you get kind of the feeling that we've done the assessment.

07:56 We know they're stable. We know this is the next best thing to do because we know that the evidence shows we get them up moving.

08:03 We're going to minimize their risk of pneumonia.

08:05 Okay. So we're going to get them out of bed.

08:07 We know they're a little anxious before the procedure because they had a loved one who had a poor outcome.

08:12 But everyone is going to be nervous after a major surgery like that, getting up and moving for the first time.

08:20 Why? Yeah, think about the level of pain that could be experiencing.

08:24 Moving is going to hurt.

08:26 No matter how we're treating your pain, big movements are going to be uncomfortable.

08:30 So keep that in mind.

08:32 Your patient is likely going to be nervous about the first time they do this, and it's important that you provide appropriate emotional support.

08:40 So while it may be your hundredth time of helping a cabg patient get up to the chair the first time, this is the patient's likely first and only experience with the opportunity to do that. So be patient.

08:54 You'll have to make yourself be intentional about taking that extra time.

08:57 Now, most patients are going to need you to explain each step, so don't take it for granted. Let them know, Hey, I'm going to walk you through every step that we're going to take. And then. And we'll do it.

09:09 We're going to go slow and steady, and myself and my colleague will be right here to make sure you are safe.

09:17 So you're going to want to explain each step to them as you go along.

09:21 Now, the big important thing here is they've got tubes and drains and lines that we want to stay inside the patient where they're supposed to be.

09:29 We don't want them to be dislodged.

09:31 So you may say something like this.

09:34 My colleague Pat and I are going to help you get out of bed for the first time.

09:38 Yes, we've done this before.

09:40 And the good news is you're doing great.

09:43 You are right on target for where your surgeon wants you to be after the procedure.

09:48 Give him a little attaboy.

09:49 You need that before you do something pretty big.

09:51 Now, what's going to happen is Pat is going to grab your legs.

09:54 I'm going to be here at your back.

09:56 We're going to slowly turn you around.

09:58 So you're sitting up on the side of the bed like you did yesterday with your legs dangling. After that, we're going to be on each side of you.

10:06 Now, I know this can be a little scary, and I'm going to ask you to hug your pillow.

10:10 That's the one that helps them with pain on their incision site.

10:13 And let us take care of your lines and tubes and drains.

10:17 We know where they all are.

10:19 We're used to working with them.

10:20 We just want you to focus on working with us, dangling on the side of the bed, and then we'll talk you through the steps of standing, pivoting and sitting right here in this nice soft chair.

10:33 Now, keep in mind, this action involves increasing the cardiac workload of the patient. So you're going to need to reassess their hemodynamics after you get them into the chair. So be ready to be able to take their vital signs and have the equipment that you need. But think about how you would want to be treated after having a procedure like a cabg. You know, you're not getting great sleep in any type of hospital.

10:55 You're scared.

10:56 You are uncomfortable.

10:58 What would you need? A very calm and assured voice to treat you with respect by telling you what's going to happen before you touch the patient or initiate an intervention.

11:10 It's really just common sense.

11:12 If you think about what would be helpful to anyone who's gone through that experience, put yourself in their shoes.

11:18 Now that you have some insight into how the nurse uses this measurement model to organize care, there are some additional things I wanted to mention about nursing care during the post-op period. See, as the patient recovers and you're caring for them, the frequency of the assessments you make of this patient generally decrease until the patient is discharged.

11:36 Now you're going to need to repeat education and perform teach backs with the clients and their loved ones always have someone else.

11:44 If the patient has a support system, which you want every patient to have one, make sure they're included in the teaching.

11:50 So perform the teach backs within, which means I show you and then the patient shows me how to do whatever we're teaching them.

11:58 You want them to know exactly what to expect with wound care, how to gradually increase their mobility, how to manage their pain, and what to expect in the recovery period at home.

12:09 So you talk to them about this before in the pre-op period, but now you want to remind them of what to expect.

12:15 The nurse will likely coordinate with the care management team for any home or equipment needs or care needs that are specific to that patient situation.

12:23 Now, that will include getting medications, participating in a cardiac rehab program, follow up outpatient appointments and emotional support group options for the patient and loved ones.

12:35 Don't overlook this when you've gone through something big like this, some people find it very helpful and beneficial to talk to other family members and loved ones who have gone through a similar procedure.

12:47 Thank you for your engagement today.

12:49 Remember, this was just an overview.

12:52 There are so many aspects of care for this type of patient before, during and after a coronary artery bypass graft procedure that we didn't cover in this video.

13:01 But they'll be reviewed in your academic and clinical training.

13:04 Remember, organizing your learning using the framework helps you to ensure a systematic and individualized approach to patient care.

13:12 Now, as you experience care of these patients during your student clinical rotations and transition to nursing practice, be sure to consult your institution's guidelines and the latest literature for detailed information on cabg care.