Avoiding Complications
1. Monitor ECG continuously for arrhythmias.
a. Evaluate possible cause of dysrhythmias—inadequate
oxygenation, electrolyte imbalance, MI, mechanical
irritation (eg, pacing wires, invasive lines, chest
tubes), and any vasopressor or inotropic medications.
b. Treat dysrhythmias immediately because they may
lead to decreased CO. Atrial or AV pacing is used to
treat sinus bradycardia or junctional rhythm with
heart rates less than 70 beats/minute.
2. Assess for signs of cardiac tamponade—arterial hypoten-
sion; rising CVP; rising left atrial pressure; muffled heart
sounds; weak, thready pulse; jugular vein distention;
falling urine output.
a. Check for diminished amount of drainage in the
chest-collection bottle; may indicate that fluid is accu-
mulating elsewhere.
b. Prepare for pericardiocentesis.
c. Assist with echocardiogram to evaluate tamponade.
3. Check cardiac enzyme levels daily. Elevations may indi-
cate MI. (Symptoms may be masked by the usual postop-
erative discomfort.)
a. Watch for decreased CO in the presence of normal
circulating volume and filling pressure.
b. Obtain serial ECGs and isoenzymes to determine
extent of myocardial injury.
c. Assess pain to differentiate myocardial pain from inci-
sional pain.
4. Monitor for hypertension or hypotension.
a. Mild systolic hypertension occurs in 48% to 55% of all
CABG patients within the first 6 hours postopera-
tively.
b. Hypotension can occur within the first 12 hours.
c. Patients with blood pressure above 70 mm Hg, with
normal preload and CO, may be treated with low-dose
dopamine.
5. Initiate measures to prevent embolization such as antiem-
bolic stockings, not putting pressure on popliteal space
(leg crossing, raising knee gatch), and starting passive and
active exercises.
a. Assess for signs of DVT and pulmonary embolism.
b. Maintain integrity of all invasive lines.
6. Monitor for bleeding.
a. Watch for steady and continuous drainage of blood.
b. Assess for arterial hypotension, low CVP, increasing
pulse rate, and low left atrial pressure and PCWP.
c. Prepare to administer blood products, I.V. solutions,
or protamine sulfate or vitamin K (AquaMEPHY-
TON).
d. Prepare for potential return to surgery for bleeding
persisting (over 300 mL/hour) for 2 hours.
e. Monitor hemoglobin levels; if the patient’s hemoglo-
bin drops below 8 g/dL, transfusions of red blood cells
or platelets may be necessary.
f. During the first 4 to 12 hours, blood recovered from
mediastinal tubes can be autotransfused to the patient.
7. Be alert for fever and signs of infection. Check blood glu-
cose levels as ordered.
a. Administer prophylactic antibiotics, as ordered, for
the first 48 hours.
b. Control higher degrees of fever through use of
hypothermia mattress.
c. Evaluate for atelectasis, pleural effusion, or pneumonia
if fever persists. (The most common cause of early
postoperative fever [within 24 hours] is atelectasis.)
d. Evaluate for urinary tract infection and wound
infection.
e. Draw blood cultures to rule out endocarditis if fever
persists.
8. Measure urine volume; less than 20 mL/hour can indicate
decreased renal function.
a. Watch BUN and serum creatinine levels as well as
urine and serum electrolyte levels.
b. Give rapid-acting diuretics and/or inotropic drugs
(dopamine [Intropin], dobutamine [Dobutrex]) to
increase CO and renal blood flow.
c. Prepare the patient for peritoneal dialysis or hemodial-
ysis if indicated. (Renal insufficiency may produce
serious cardiac dysrhythmias.)
Community and Home Care Considerations
Preparing the patient with cardiovascular disease or after car-
diac surgery for the return home and/or optimizing the
patient’s health status in the home are important nursing
functions. The key areas on which to focus include assessment,
education, and evaluating responses.
Assessment
1. Optimally, the discharge plan begins at facility admission.
The patient’s physical condition will determine to some
extent his needs at home (ie, ability to care for self).
However, the available support systems will allow the
nurse to individualize the care plan.
2. Assess the patient’s functional abilities. Patients with car-
diovascular disorders may need to conserve their energy
and rest of