1-33
1-33. POSTOPERATIVE CARE
Postoperative care for patients who have had surgery of the heart or great vessels is generally much the same as that given to other chest surgery patients. A possible exception to this generalization is care for the patient who has had surgery of the coronary arteries (see paragraph 1-33d below). The first 48 hours following cardiovascular surgery are the most critical, and a high degree of alertness and skill in nursing care are essential if death is to be prevented. Intensified nursing care should continue for at least the first five postoperative days.
a. Vital Signs. Pulse, blood pressure, and respiration must be taken and recorded every 15 minutes until they stabilize, usually after 4-8 hours. In addition, cyanosis must be watched for and its cause corrected. A systolic pressure of only 80 or 90 in cardiovascular (CV) surgical patients is no cause for alarm as these patients tolerate the lower pressure well. The physician should be called immediately if the systolic pressure is below 80. The exception is the coronary artery surgical patient, whose pressure should be not more than 10 mm. below the preoperative pressure. The apical pulse, taken over the heart with a stethoscope, most immediately reflects the activity of the heart; however, the arterial pulse should be taken not only from the radial artery at the wrist, but also from arteries of all limbs to detect the presence of an embolus as early as possible. Temperatures outside the 97 to 102F range should be reported. Higher temperatures may be an indication of shock or cardiac decompensation. The respiratory character as well as the respiratory rate should be noted. Using the stethoscope aids in detecting changes in character. Changes noted should be reported promptly.
b. Oxygen Therapy. Oxygen is given by facemask, usually at the rate of 8 liters per minute. After the patient has fully reacted, a nasal cannula is substituted and oxygen is continued at 4 to 6 liters per minute until the physician orders discontinuance. Peripheral signs of cyanosis and ischemia must still be watched for, however. Mottling or blanching of the skin in an extremity--particularly if it is accompanied by other phenomena such as pain, numbness, tingling, or loss of motion--may indicate the presence of an embolus and should be immediately reported.
c. Psychological Considerations. Any signs of disorientation, such as failure to recognize a member of the family or familiar surroundings, should be reported. A transient state of depression may be expected in the CV surgical patient. In an occasional patient, the depression will degenerate into suicidal tendencies. Postoperative depression may be prevented or its intensity lessened through preoperative explanation of the upcoming procedure and sympathetic consideration of the patient's fears and concerns.
d. Positioning and Turning. Usually, the patient is kept in the dorsal recumbent position until his systolic pressure is more than 100. On specific orders from the physician, a CV surgical patient, other than one who has had coronary artery surgery, may be raised to a semi-Fowler position and may be turned from side to side every two hours. A blood pressure reading must be taken immediately before and 5 minutes after the patient is raised. If the blood pressure drops after the patient is raised, the head of the bed and the patient must be returned to horizontal for at least 30 minutes before the procedure is repeated. The coronary artery patient is usually kept in dorsal recumbent position for 48 hours before any attempt is made to change his position because, up to that time, turning the patient as little as 15 degrees to one side may cause a serious drop in blood pressure. When turning is permitted, the coronary artery patient should be turned from back to right side (and vice versa) every 2 hours.
e. Pain. Ribs that were retracted during surgery are the major sources of postoperative pain in the CV surgical patient. During the first 24 to 48 hours, Demerol is given on a schedule and in a quantity sufficient to keep him reasonably comfortable but not enough to depress his mental
outlook and cough reflex. After this initial period, other causes for continued restlessness--such as oxygen deprivation, fear, and positional discomfort--should be looked for and corrected.
f. Cough. After stabilization, CV surgical patients should be encouraged to raise deeply lodged secretions by coughing with support in the same manner as other surgical patients. Such coughing is usually effective, but if it is not, endotracheal suctioning must be employed. Sometimes a mucolytic agent applied in aerosol form may be helpful.
g. Underwater Seal Drainage. Nursing care with regard to CV patients with underwater seal drainage is generally the same as that for other chest patients with such drainage equipment in place. Drainage of about 400 to 500 ml of bloody fluid is to be expected from heart surgery patients during the first 24 hours. Absence of drainage fluid in the water seal setup indicates that fluid may be accumulating in the thorax. Thus, drainage volume must be carefully observed and recorded.
h. Gastric Suction. Temporary gastric distention is a common occurrence in CV surgical patients. The stomach is intubated and suction applied to reduce distention and relieve any pressure exerted on the heart by the distended stomach.
i. Diet. With permission of the physician, fluids may be given as soon as the patient can tolerate them. The first fluids given should be lukewarm and should not be fruit juices, as they may cause nausea. Cardiovascular surgical patients are normally markedly thirsty, and they will drink large quantities of fluids. If fluid is retained, intake may have to be restricted. Nursing personnel must diligently monitor and record fluid intake and output. Also, it may be necessary to weigh the patient daily. The physician probably will permit returning the patient to a soft or normal diet as soon as the patient desires solid food. Solid food should be withheld from the coronary artery surgery patient until abdominal cramps and gas no longer persist.
j. Exercise. The patient, upon regaining consciousness, is encouraged to breathe deeply through the nose deliberately and quietly to ventilate and expand the lungs. Care must be taken not to tire the patient. Other voluntary body movement and exercise are encouraged after the first 24 hours. The patient is encouraged to comb his hair, reach for objects within normal reach, and then use a pull to raise himself. A pull may be made from wide gauze attached to the foot of the bed and extending to within the patient's reach. A T-handle may be inserted or a knot tied in the end of the pull to facilitate easier grasping. From about the 5th to the 8th day, as determined by the physician, the patient is allowed to dangle his feet for gradually increasing lengths of time, then gradually allowed out of bed more and more until the patient is fully mobile, usually by the 12th to 14th day.
