Post-op management of cardiopulmonary patients

• Coronary artery disease aka CAD

  • presence of an obstruction that limits coronary blood flow but does not inhibit heart muscle function
  • narrowing or blockage of the coronary arteries limiting the amount of oxygen delivered to the heart muscle
• CAD is caused by a condition known as atherosclerosis
• atherosclerosis is a condition in which fatty deposits (plaque) accumulate inside the artery wall and blocks blood flow

  • causes hardening and narrowing of the coronary arteries
• PCI = percutaneous coronary intervention

  • encompasses atherectomy, angiplasty, and stenting
  • a catheter is inserted through femoral or radial artery and moved into the coronary arteries at the site of blockage
• PCI

  • patients can be ambulatory 3 hours after if accessed through the groin
  • if accessed through the radial artery = no waiting
• Percutaneous transluminal coronary angioplasty

  • PTCA - a type of PCI
  • When a coronary artery is partially or totally occluded by plaque
  • a balloon is inserted through the femoral or radial artery and then inflated to compress the plaque against the wall
• Atherectomy is another type of PCI that is more high risk

  • removes plaque
  • 4 devices: rotational, orbital, directional, or laser
  • increased risk of perforation and decreased effectiveness
  • used more for peripheral vascular disease
  • more successful when used right before stunting to allow for optimal stent expansion
• Stenting is another type of PCI

  • used to keep an artery open once the balloon is removed
  • BMS - bare metal stent
  • increased risk of restenosis, clot formation, stroke, and MI
  • DES - drug eluting stent
  • coated in anti-clotting medication
• PCI PT implications

  • be aware of the time of the procedure
  • inspect surgical sites prior to mobilization
  • start with lower intensity
• Coronary artery bypass graft aka CABG is used when an atherosclerotic occlusion has progressed to a point that PCI cannot be used
• CABG

  • vascular grafts are harvested from the saphenous vein or internal mammary arteries
  • requires a median sternotomy (cut down the center of the chest)
  • average hospital stay = 4 days
• CABG = coronary artery bypass grafting

  
• sternal precautions

  • restrictions on use of arms 6-12 weeks post-op
  • traditional precautions
  • no pushing or pulling
  • no lifting both arms up or to the side
  • no lifting heavier than 5-10 lbs
• Complications of CABG

  • bleeding
  • stroke
  • arrythmia
  • pneumothorax
  • pneumonia
  • acute kidney injury
  • infection
  • difficulty weaning off the ventilator
• Permanent pacemaker placement

  • is continuous
  • used to control different types of arrythmias
  • Indications
  • SA node disorders - bradyarrythmias
  • AV node disorders - heart blocks
  • Tachyarrythmias
• Pacemaker precautions

  • restricted L shoulder movement above 90 for 4 weeks
  • sling worn first 24 hours and then kept on at night
  • limit pushing/pulling
  • no lifting heavier than 10 lbs
• ICD placement

  • aka implantable cardioverter defibrillator
  • detects life threatening arrhythmias and delivers a shock to restore normal heart rhythms
• NG tube

  • to deliver nutrients to patients who cannot orally intake food
  • safe to mobilize
• NG tube precautions

  • HOB >30 during feed and for 1 hour after
  • avoid trendelenberg
• Telemetry

  • allows for continuous surveillance of HR/rhythm
  • can also monitor SpO2, BP, and RR
  • safe to mobilize
• Chest tube is surgically inserted through the chest wall into the space between the ribs and lungs

  • drains air and blood
  • safe to mobilize
• Temporary pacemaker

  • for post-op arrhythmias
  • allows for temporary pacing of the heart
  • pt on bed rest for one hour if leads are pulled
  • safe to mobilize
• Pulmonary Artery Catheter

  • aka Swan-Ganz Catheter aka Swan
  • Allows for direct measurement of right arterial pressure, pulmonary artery pressure, pulmonary capillary wedge pressure
  • allows for determination of cardiac output
• Swan—Ganz Catheter

  • placed through internal jugular or subclavian vein to the vena cava to the right atrium, right ventricle, and ending in the pulmonary artery
  • safe to mobilize
• Arterial line allows for continuous blood pressure management

  • inserted into the artery; radial or femoral
  • displays SBP/DBP and the MAP
  • MAP norms = 70-110
• If the transducer of the arterial line is too low = BP will read high

  • if too high = BP will read low
  • if dislodged, apply pressure right away
  • safe to mobilize
• Intra aortic balloon pump

  • assists with circulation of blood through the body
• intra aortic balloon pump is used to augment blood flow through the coronary arteries

  • increase cardiac output
  • decrease afterload by lowering SBP
  • decrease HR
  • inserted in femoral artery
  • NOT safe to mobilize
• Deflated intra aortic balloon pump:

  • ventricular systole
  • assists with emptying the aorta
• inflated intra aortic balloon pump

  • diastole
  • restores arterial pressure and coronary perfusion
• bed rest for intra aortic balloon pump with a femoral insertion

  • no hip flexion past 30 degrees
  • OOB activities contraindicated until removed or moved to left axillary