NOVEMBER 1984, VOL 40, NO 5 AORN JOURNAL

The Cardiac Surgical Patient GUIDELINES FOR ASSESSMENT

Marian Walsh, RN his article presents broad preoperative, intraoperative, and postoperative guide- T lines for assessing the adult cardiac sur-

gical patient. The focus is on assessment skills, their systematic application to the patient, and their contribution to clinical decision making.

Preoperative Assessment

uring the preoperative period, the nurse considers the patient's history, physical D assessment, laboratory determinations,

and teachinghearning needs. Of these catego- ries, nurses traditionally feel the least comfort- able with physical assessment. It is beyond the scope of this article to detail specific techniques; it will, however, provide an outline. The reader is referred to the referenced text on physical assessment and encouraged to practice examina- tion skills to develop proficiency.

I suggest the following outline for preopera- tive assessments for the cardiac surgical patients.

History Cardiovascular system-review signs and

symptoms to establish a base line and to deter- mine functional state. Those most common to the cardiac surgical patient are chest pain, palpa- tions, dyspnea, paroxysmal nocturnal dyspnea, orthopnea, cyanosis, peripheral edema, hyper- tension, varicosities, and intermittent claudica- tion.

Related systems-review neurological, res- piratory, renal, and gastrointestinal systems be- cause they may be affected by decreased cardiac

output, congestive heart failure, and/or embolic phenomena.

Relevant past-document the following any history of major illness such as rheumatic fever, bacterial endocarditis, myocardial in- farction, diabetes mellitus, cancer, kidney disease, asthma, coagulopathies, or other sys- temic disease allergies medications taken currently or in the past (particularly propranolol , digitalis, antiar- rhythmics) past surgeries exposure to harmful agents (particularly to- bacco and alcohol). Psychlogicallsocial data-ask How is the patient and his family coping with the anticipation of the surgery? What does the surgery mean to the patient?

0 What lifestyle alteiations are anticipated? How have the patient and family dealt with stressful situations in the past?

Physical Assessment' The perioperative nurse should assess the fol-

Marian Walsh, RN, MSN, is a practitionerlteacher in the department of ORlsurgical nursing at Rush- Presbyterian-St Luke's Medical Center, Chicago. She received her master of science degree in nursingfrom Rush University, and her bachelor's in nursing from the College of St Catherine, St Paul, Minn.

The author wishes to express special thanks to Patricia Moss, RN, MS, for assistance in refining the intraoperative content in this article.

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I d valvular stenosis or regurgitation, and/or coro-

I

nary artery lesions.

Teachingharning Consider the patient’s readiness to learn and

ability to understand the content to be taught. Document all progress.

Intraoperative Assessment

he nurse assesses the patient’s anxiety and comfort levels before the patient is T brought to the operating room and con-

tinues to observe the patient’s reactions until Tricuspid 2/ anesthesia is induced. The circulating nurse as-

sesses the patient’s skin before putting any elec- trodes or electrosurgical grounding pads in place. Throughout the procedure, the OR nurse assesses the patient’s position and alignment making sure there are no pressure points that may

Fig heart in an orderly fashion.

lowing during the preoperative phase

Identify ‘andmarks and proceed t~ assess the

- - general appearance and behavior baseline vital signs, weight, and height cardiac examination a. inspection and palpation4ocument the location of the point of maximal impulse, presence of heaves, thrills, or abnormal pulsa- tions (Fig 1). b. auscultationdocument the pulse rate, rhythm, and quality; note the presence of SS, S4, murmers, clicks, and splits. peripheral vascular examination a. inspect the patient for presence of jugular venous distention, peripheral edema, vari- cose veins, uneven hair distribution, and al- teration in color. b. palpate extremities and document skin temperature, presence or absence of periph- eral pulses, their symmetry and strength. c . auscultate for bruits over the carotid, iliac, renal, femoral arteries.

lead to nerve damage or skin breakdown. Blood loss is assessed by evaluating the amount of blood within suction containers and sponges. In addition, nursing assessments are made to antic- ipate the need for additional instruments, anes- thetic medications, andor equipment.

The following intraoperative documentation should be made by the circulating nurse. Procedure

vessels bypassed valves replaced and type of prosthesis used any other procedure performed such as

Type of anesthesia Monitoring 0 vital signs 0 electrocardiogram readings 0 hemodynamic measurements. Cardiopulmonary bypass

time on bypass ease of termination.

aneurysm resection, valvuloplasty .

Preoperative Laboratory Data Examine the patient’s chart for electrolytes,

blood ureanitrogen, creatinine, coagulation pro- file, complete blood count, urinanalysis, chest x-ray, and electrocardiogram reports. Document significant findings of the cardiac catheterization such as left ventricular function, presence of

Placement of indwelling catheters, infusion lines, and drainage tubes

Patient’s tolerance of procedure

Any unusual incidents

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Postoperative Assessment

he postoperative assessment of cardiac surgical patients demands frequent T monitoring of all systems the first 24 to

48 hours. The following guidelines are based on a body system format, but many of these as- sessments can and should be made simultane- ously. Documentation can be simplified by using a flow sheet.

Cardiovascularfunction. Vital signs are often manipulated by phmocological interventions. The systolic blood pressure is usually maintained within 20 mm Hg of the patient’s base line blood pressure. Appropriate vasodilators, vasopres- SOTS, or inotropic agents are often used. The heart rate is best maintained between 60 to 120 beats per minute. When evaluating the heart rate, the nurse interprets the electrocardiogram rhythm and controls any antiarrhythmic agents ordered. Central venous and pulmonary artery pressures a~ maintained within base line values with fluid or colloid replacement. The postopera- tive cardiac physical assessment includes inspec- tion, palpation, and auscultation. Peripheral vascular assessment is important especially in the leg from which a venous graft was taken. Document bilateral peripheral pulses, color, temperature, edema, and the presence of a Ho- man’s sign.

Respiratory function. Document the rate, rhythm, and depth of respirations. If the patient is being ventilated, document all the parameters. Physical findings again include inspection, aus- cultation, and percussion. A cough as well as sputum characteristics need to be assessed. Often a change in the patient’s orientation may indicate hypoxia and be indicative of a respira- tory problem, Frequent arterial blood gas analysis and chest x-rays should be correlated with other findings.

Fluid and electrolyte balance. Assess all labo- ratory values especially electrolytes and com- plete blood counts. Intravenous intake should be compared with output from urine, chest tubes, and nasogastric tubes. The specific gravity of the urine will be a useful gauge by which to assess dehydration. Central venous and pulmonary ar-

Table 1

Postoperative Complications in Cardiac Surgical Patients

0 cardiogenic shock cardiac tamponade

0 arrhythmias 0 hemorrhagelhypovolemia

atelectasis, pneumonia 0 pneumothorax

pulmonary embolus 0 metabolic acidosis/respiratory alkalosis

renal dysfunction 0 cerebral vascular accident

anemia 0 postoperative depression

tery pressures give an indication of intravascu- lar volume. Lung sounds and daily weights may indicate a fluid overload.

Neurological finction. The patient should be checked for an appropriate mental awareness of his surroundings. See that he can move all body parts and that his sensation is intact.

Pain and comfort. The nurse should document the patient’s subjective account of his pain and note the location, quality, and onset to distin- guish normal surgical pain from angina, pulmo- nary embolism, or pleurisy. After pain medica- tion is given, document the patient’s response and if it affected his rest and sleep pattern.

Psychological adaptation. The patient’s signs and symptoms of anxiety, his response to the environment, and nature of the family interac- tions will all give clues to the psychological coping mechanisms.

Teachingllearning needs. Assess the pa- tient’s ability and readiness to begin learning discharge instructions. The nurse can plan specific content to be taught based on this as- sessment.

The analysis of these systemic assessments can lead to the identification or prevention of specific postoperative complictions. See Table 1 for a summary of some common postoperative complications.

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Table 2 Clinical Decision-making Process

Assessment data (6 hours post-CABG) BP 70-80 P 110

4-50 - You think - decreased level of consciousness urine output 20 cclhr arms and legs cool, pale, no cyanosis

Additional data

Possible nursing diagnosis Inadequate cardiac output related to hypovolemia,

or a slowly developing cardiac tamponade

or heart failure

chest tube output 50 cclhr CVP 5 cm Ha0

*

/ Therapy

Medical therapy decision

Rapid volume replacement begun intravenously

+

Nursing diagnosis Fluid volume deficit

A number of nursing diagnoses may be identified for the cardiac surgical pa- . tient. The following is a summary of the

major diagnoses along with the most common underlying pathophysiology and relevant nurs- ing assessment.

Nursing Diagnoses will yield relevant data. For example, decreasing level of consciousness and urine output and evi- dence of decreased peripheral perfusion may all occur with a low cardiac output.

Alteration in tissue perfusion related to hypo- tension, hypovolemia, hypothermia, increased peripheral vascular resistance, and/or peripheral embolism.

Alteration in cardiac output related to conges- tive heart failure, cardiogenic shock, hypovo- lemia, cardiac tamponade, and/or arrhythmias.

Cardiac output (CO) is determined by the heart rate and stroke volume (amount of blood ejected from left ventricle with each beat). Therefore, anything that affects heart rate and stroke volume affects cardiac output. Elec- trocardiogram rates and rhythms affect cardiac output as do blood pressures and central venous and pulmonary artery pressures. Direct cardiac output measurements via the thennodilution method should be obtained if possible. Because all other body systems are affected by a low cardiac output, astute assessments of all systems

Alteration in comfort related to postoperative

Each complaint of pain should be individually analyzed. A delicate balance between pain relief and respiratory depression must be achieved with any pain medication administered.

pain.

Alteration in neurological status related to hypoxia, embolic phenomena, cerebral hypoper- fusion.

Early assessment of the patient's level of con- sciousness is often difficult because of anes- thesia recovery times, endotracheal tubes, or other barriers to communiction. Each nurse de-

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NOVEMBER 1984, VOL 40, NO 5 AORN JOURNAL

velops a skill in making judgments about the patient’s mental status.

Neurological peripheral impairment is also a potential problem. As soon as possible, deter- mine that the patient has regained motor and sensory function of arms and legs.

Potential for infection related to surgical proce- dure, invasive catheters, and accumulation of pulmonary secretions.

Summary. The nurses’ assessments form the basis for clinical decision making. Table 2 is an example of how decisions can be made using assessment data. The emphasis is on the decision-making process rather than on specific

Note 1 . Barbara Bates, A Guide to Physical Examina-

tion, 2nd ed. (Philadelphia: J B Lippincott, 1979)

therapeutic methods. 0

139- 172.

Audiovisual Review As more sophisticated instruments are used in operating rooms, the OR staff must be well instructed in their care and maintenance. Air instruments are now used extensively by the surgical specialties, and this excellent 10-minute film, Air Instruments in Neurosurgery, covers care and use of the craniotome and its components.

Key points in cleaning, maintaining, and assembling each component are emphasized. OR nurses, surgical technologists, and instrument room staff will benefit from this film. It will teach the novice team member and serve as a thorough review for experienced staff.

available in %-inch videocassette from 3M Surgical Products representatives. You may also write to: Health Care Products/3M, Po Box 33050, St Paul, MN 55133. There is no charge for the film.

Air Instruments in Neurosurgery is

JEAN SPENCER, RN AUDIOVISUAL COMMIITEE

Correction in Home Study Credit Two contact hours (.2 CEU) will be granted for the September Home Study Program, “Total Parenteral Nutrition. ”

The introductory remarks on page 346 of that issue incorrectly stated that one contact hour would be granted.

Skill Predictors For Surgical Residents A study on the neuropsychological predictors of operative skill among 120 general surgery residents was published in the Aug 14 issue of Surgery. The study was done at the Loyola University Medical Center, Maywood, Ill, and at Northwestern University Medical School, Chicago.

A noticeable proportion of surgery residents fail to exhibit desirable performance in the operating room, despite demonstrations of superior verbal abilities and motivation. It would then seem that the ability to acquire knowledge is not a sufficient condition for operative skill, the study states.

Standard neuropsychological tests were given to provide measurements of nonverbal abilities minimally related to academically based measures of verbal intelligence. There were thee specific areas of interest: visual-spatial perception, motor sequencing and fine-motor coordination, and stress tolerance.

In evaluating the importance of nonverbal abilities, the study showed that pure manual dexterity was not the major dimension distinguishing the proficient surgical performance from the mediocre. Rather, nonverbal, visual-spatial problem-solving abilities, and the ability to distinguish essential from nonessential detail appeared most crucial to superior technique.

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