Nursing Diagnosis and Care Plan for CABG: Comprehensive Guide for Post-Operative Care

Coronary Artery Disease (CAD) encompasses conditions affecting the arteries supplying the heart with vital nutrients, blood, and oxygen. Atherosclerosis, a primary cause of CAD, involves lipid accumulation within arterial walls, forming plaques that narrow arteries and impede blood flow. This process elevates the risk of angina and myocardial infarction, posing significant health threats.

CAD is a progressive disease, often advancing silently for years before noticeable symptoms such as angina, shortness of breath, and fatigue manifest. When coronary artery blood flow is severely compromised, myocardial ischemia and infarction occur, demanding prompt medical intervention. For patients with multiple narrowed coronary arteries, a Coronary Artery Bypass Graft (CABG) surgery becomes a crucial intervention to restore adequate blood supply to the heart muscle.

This article provides a comprehensive guide for nurses on the nursing process, including nursing assessment, interventions, and care plans specifically tailored for patients undergoing CABG. This detailed approach ensures optimal post-operative care and recovery.

Nursing Process in CABG Post-Operative Care

Managing CAD, especially in patients undergoing CABG, necessitates a holistic approach focusing on risk factor modification and symptom management. Nurses play a pivotal role in health promotion, educating patients about the disease, surgical procedures like CABG, and essential lifestyle adjustments post-surgery.

Post-CABG, nursing care is critical for monitoring recovery, preventing complications, and facilitating rehabilitation. This includes meticulous assessment, targeted interventions, and comprehensive care planning to address the unique needs of patients after CABG surgery.

Nursing Assessment Post-CABG

The initial nursing assessment post-CABG is crucial, involving the collection of physical, psychosocial, emotional, and diagnostic data. This section outlines subjective and objective data relevant to patients recovering from CABG surgery.

Review of Health History (Pre- and Post-CABG Considerations)

1. Assess General Symptoms Post-CABG: Note patient complaints and general symptoms, which may include:

• Chest pain (though often different in nature post-CABG, requiring differentiation from pre-operative angina)
• Shortness of breath (dyspnea) at rest and during activity
• Rapid breathing (tachypnea)
• Difficulty breathing while lying or sitting (orthopnea)
• Fatigue and weakness
• Palpitations
• Lower extremity edema
• Pain at the incision sites (chest, leg if saphenous vein graft used)

2. Investigate Chest Pain Characteristics: Post-CABG chest pain needs careful evaluation. Differentiate between:

• Incisional pain: localized, related to movement, reproducible on palpation.
• Angina: though CABG aims to alleviate angina, it can still occur. Assess characteristics: tightness, squeezing, heaviness, triggers, radiation.
• Non-cardiac chest pain: musculoskeletal, gastrointestinal.

3. Review Pre-operative and Post-operative Risk Factors: While some risk factors are non-modifiable, understanding both pre-existing and new risks post-CABG is vital.

Non-modifiable risk factors (relevant pre-operatively and in long-term management):

• Age: Risk increases with age.
• Gender: While men are generally at higher risk, women’s risk increases post-menopause.
• Family history of ischemic heart disease: Significant family history increases risk.
• Race/ethnicity: Certain minority groups have higher CAD incidence.

Modifiable risk factors (crucial to address post-CABG):

• Hypertension: Post-operative blood pressure management is critical.
• Hyperlipidemia/hypercholesterolemia: Lipid management remains essential post-CABG to prevent graft occlusion and further CAD progression.
• Diabetes or insulin resistance: Strict glycemic control is vital for wound healing and overall cardiovascular health post-CABG.
• Kidney disease: Renal function can be affected by CABG; pre-existing kidney disease requires careful monitoring.
• Tobacco use: Smoking cessation is paramount post-CABG to improve graft patency and overall outcomes.
• Obesity: Weight management is essential for long-term cardiovascular health.
• Physical inactivity: Cardiac rehabilitation and gradual activity resumption are key.
• Diet: Heart-healthy diet is crucial post-CABG.
• Stress: Stress management techniques are important for recovery.
• Alcohol use: Moderation or abstinence is generally recommended.
• Lack of sleep: Adequate sleep promotes healing and reduces stress.

4. Review Medications and Treatment Record: Note pre-operative medications and meticulously track post-operative medications, including pain management, anticoagulants, antiplatelets, and cardiac medications. Document details of the CABG procedure itself (grafts used, vessels bypassed).

Physical Assessment Post-CABG

1. Monitor Vital Signs: Frequent vital sign monitoring is essential post-CABG. Expect fluctuations and trends indicative of recovery or complications.

• Heart rate: Monitor for tachycardia (anxiety, pain, hypovolemia) and bradycardia (medication side effects, heart block).
• Blood pressure: Monitor for hypertension (pain, anxiety, fluid overload) and hypotension (hypovolemia, cardiac dysfunction).
• Respiratory rate and oxygen saturation: Assess for tachypnea, dyspnea, and hypoxemia.
• Temperature: Monitor for fever, which could indicate infection.

2. EKG and Telemetry Monitoring: Continuous telemetry monitoring is standard post-CABG to detect arrhythmias and ischemia. 12-lead EKGs are performed regularly and with any chest pain or changes in condition.

3. Systemic Assessment Approach (Post-CABG Specifics):

• Neck: Assess for jugular vein distention (JVD), which could indicate fluid overload or right heart failure.
• CNS: Assess level of consciousness, orientation, and neurological deficits (potential post-operative complications).
• Cardiovascular:
  • Auscultate heart sounds: Note murmurs, rubs, or gallops.
  • Monitor heart rhythm for arrhythmias (atrial fibrillation is common post-CABG).
  • Assess chest incision site for drainage, redness, swelling, and signs of infection.
• Circulatory:
  • Assess peripheral pulses (radial, dorsalis pedis, posterior tibial) bilaterally, noting strength and equality.
  • Evaluate capillary refill.
  • Monitor for signs of peripheral edema.
• Respiratory:
  • Auscultate breath sounds: Note crackles, wheezes, or diminished breath sounds.
  • Assess respiratory effort and depth.
  • Monitor chest tube drainage (if present), noting color, amount, and consistency.
• Gastrointestinal: Assess bowel sounds, abdominal distention, nausea, and vomiting.
• Genitourinary: Monitor urine output; decreased output can indicate renal hypoperfusion.
• Lymphatic: Assess for peripheral edema, especially in the legs if saphenous vein graft was used.
• Musculoskeletal: Assess pain at incision sites, mobility, and strength.
• Integumentary: Assess skin color, temperature, and moisture. Monitor surgical incision sites for signs of infection.

4. Pain Assessment: Regularly assess pain using a pain scale. Differentiate between incisional pain, angina (less likely post-CABG but possible), and other pain sources.

Diagnostic Procedures Post-CABG

1. Monitor for Arrhythmias: Post-CABG patients are at risk for various arrhythmias. Continuous EKG monitoring is crucial. Note any new onset arrhythmias, conduction abnormalities, or ST-segment changes indicative of ischemia.

2. Obtain Blood Work Samples: Analyze the following:

• Complete blood count (CBC): Monitor for infection (WBC), anemia (RBC, hemoglobin, hematocrit), and platelet count (especially if anticoagulation is used).
• Electrolytes: Monitor potassium, magnesium, calcium, and sodium levels, as imbalances can contribute to arrhythmias.
• Renal function tests (BUN, creatinine): Assess kidney function post-CABG, especially if contrast dye was used during pre-operative angiography or if the patient has pre-existing renal issues.
• Cardiac enzymes (Troponin, CK-MB): Monitor for myocardial damage, although post-CABG enzyme elevation is expected to some degree due to surgical trauma. Look for trends and significant increases.
• Coagulation studies (PT/INR, aPTT): Monitor if anticoagulation therapy is used.
• Glucose levels: Maintain tight glycemic control, especially in diabetic patients.

3. Chest X-ray: Post-operative chest X-ray is typically performed to assess lung fields, mediastinal width, and placement of tubes and lines.

4. Echocardiogram: May be performed post-CABG to assess left ventricular function, valve function, and overall cardiac performance.

5. Further Investigations (if needed):

• Stress testing: May be performed later in recovery to assess functional capacity and for ongoing angina evaluation.
• Cardiac CT angiography: May be used to assess graft patency if concerns arise.
• Coronary angiography: In rare cases, repeat angiography may be necessary if graft occlusion or recurrent ischemia is suspected.

Nursing Interventions Post-CABG

Nursing interventions are paramount for patient recovery after CABG. These interventions focus on promoting perfusion, managing symptoms, facilitating cardiac rehabilitation, ensuring safety, and preventing complications.

Promote Perfusion Post-CABG

1. Maintain Graft Patency:

• Administer antiplatelet medications: Aspirin and often clopidogrel or ticagrelor are crucial to prevent graft thrombosis. Ensure timely administration.
• Manage blood pressure: Maintain optimal blood pressure to promote graft flow but avoid excessive hypertension that can strain grafts.
• Control cholesterol levels: Continue or initiate cholesterol-lowering medications (statins) to prevent progression of atherosclerosis in native vessels and grafts.

2. Optimize Cardiac Output:

• Fluid management: Maintain euvolemia. Monitor fluid balance carefully, avoiding both fluid overload and dehydration.
• Inotropic support: Administer inotropic medications (e.g., dobutamine, milrinone) if ordered to improve contractility in patients with low cardiac output.
• Afterload reduction: Administer vasodilators (e.g., nitroglycerin, nitroprusside) if needed to reduce afterload and improve cardiac output, under careful hemodynamic monitoring.

3. Prevent Blood Clots (DVT/PE):

• Early ambulation: Encourage early and frequent ambulation as tolerated to improve circulation and prevent venous stasis.
• Sequential compression devices (SCDs): Apply SCDs to lower extremities to promote venous return.
• Anticoagulation: Administer prophylactic anticoagulation (e.g., subcutaneous heparin or enoxaparin) as ordered to prevent deep vein thrombosis (DVT) and pulmonary embolism (PE).

Manage Symptoms Post-CABG

1. Pain Management:

• Assess pain regularly: Use pain scales to quantify pain and assess characteristics.
• Administer analgesics: Provide adequate pain relief with prescribed analgesics, which may include opioids (initially), NSAIDs, and acetaminophen.
• Non-pharmacological pain relief: Employ techniques like positioning, splinting incision during coughing, relaxation techniques, and distraction.

2. Respiratory Management:

• Encourage deep breathing and coughing exercises: Prevent atelectasis and pneumonia.
• Incentive spirometry: Instruct and encourage use of incentive spirometry.
• Suctioning: Perform tracheal suctioning as needed to clear secretions.
• Oxygen therapy: Administer supplemental oxygen as needed to maintain adequate oxygen saturation.
• Monitor chest tube function: If chest tubes are present, ensure patency and appropriate drainage.

3. Wound Care:

• Incision care: Maintain clean and dry incision sites. Monitor for signs of infection (redness, drainage, warmth, pain). Follow hospital protocols for dressing changes.
• Leg wound care (if saphenous vein graft harvested): Elevate leg to reduce edema, monitor for infection, and encourage ambulation as tolerated.

4. Manage Anxiety and Emotional Support:

• Provide reassurance and education: Explain procedures and answer questions to reduce anxiety.
• Encourage expression of feelings: Create a supportive environment for patients to express their fears and concerns.
• Address psychological needs: CABG is a major life event; be aware of potential depression and anxiety. Refer to social work or mental health professionals as needed.

Cardiac Rehabilitation Post-CABG

1. Phase I Cardiac Rehabilitation (Inpatient):

• Early mobilization: Progressive activity plan starting with bed mobility, chair sitting, and ambulation.
• Patient education: Educate on medications, wound care, risk factor modification, diet, activity guidelines, and warning signs.
• Discharge planning: Coordinate discharge plans, including home care, medications, follow-up appointments, and referral to Phase II cardiac rehabilitation.

2. Phase II Cardiac Rehabilitation (Outpatient):

• Supervised exercise program: Individualized exercise plan to improve cardiovascular fitness.
• Risk factor modification education: Reinforce education on lifestyle changes, diet, smoking cessation, stress management, and medication adherence.
• Psychosocial support: Group sessions and individual counseling to address emotional and psychological needs.

3. Home and Community Health Services: Ensure smooth transition to home care, coordinating necessary services and follow-up appointments.

4. Promote Adherence to Plan: Emphasize the importance of long-term adherence to medications, lifestyle modifications, and cardiac rehabilitation for optimal outcomes and reduced readmission risk.

Lower the Risk: Prevention Measures Post-CABG

1. Lifestyle Modification Reinforcement: Continuously reinforce the importance of:

• Regular exercise: Tailored exercise program within cardiac rehabilitation.
• Heart-healthy diet: Low saturated fat, low cholesterol, low sodium, high fiber diet.
• Smoking cessation: Provide resources and support for smoking cessation.
• Stress management: Teach and encourage stress reduction techniques.
• Medication adherence: Emphasize the importance of taking medications as prescribed.

2. Manage Comorbidities: Aggressively manage conditions like diabetes, hypertension, and hyperlipidemia to optimize cardiovascular health post-CABG.

3. Patient Education on Warning Signs: Educate patients and families on recognizing symptoms requiring immediate medical attention (chest pain, shortness of breath, palpitations, signs of infection).

4. Follow-up with Cardiologist: Emphasize the importance of regular follow-up appointments with a cardiologist for monitoring and ongoing management.

Provide Safety Post-CABG

1. Bleeding Precautions: Post-CABG patients are often on antiplatelet and/or anticoagulant medications, increasing bleeding risk.

• Implement bleeding precautions: Gentle toothbrush, electric razor, avoid nose blowing forcefully, prevent constipation, avoid contact sports.
• Monitor for signs of bleeding: Assess for bruising, petechiae, bleeding gums, hematuria, melena, and signs of internal bleeding.

2. Infection Prevention: Surgical site infections are a risk post-CABG.

• Meticulous wound care: Follow sterile technique for dressing changes.
• Monitor for signs of infection: Assess incision sites regularly.
• Promote hand hygiene: Educate patients and visitors on hand hygiene.

3. Fall Prevention: Patients may be weak and dizzy post-CABG, increasing fall risk.

• Assess fall risk: Use fall risk assessment tools.
• Implement fall precautions: Keep environment clutter-free, ensure adequate lighting, assist with ambulation, educate patient on fall prevention strategies.

4. Medical Identification: Advise patients to wear medical identification indicating history of CABG, medications (especially antiplatelets/anticoagulants), and relevant medical conditions.

Nursing Care Plans Post-CABG

Following CABG surgery, several nursing diagnoses are pertinent. Nursing care plans help prioritize assessments and interventions to achieve short-term and long-term goals. Examples of common nursing diagnoses and associated care plan components post-CABG are outlined below:

Acute Pain Post-CABG

Nursing Diagnosis: Acute Pain related to surgical incision, tissue trauma, and post-operative procedures.

Related to:

• Surgical incision (chest, leg if vein graft)
• Tissue trauma from surgery
• Post-operative procedures (chest tubes, drains)

As evidenced by:

• Reports of pain at incision sites
• Pain behaviors (guarding, grimacing, restlessness)
• Increased vital signs (tachycardia, hypertension)
• Limited mobility due to pain

Expected outcomes:

• Patient will report pain is managed to a tolerable level (e.g., pain score ≤ 3/10).
• Patient will demonstrate effective pain management strategies (e.g., splinting incision during coughing, using relaxation techniques).
• Patient will participate in post-operative activities with managed pain.

Assessment:

1. Assess pain characteristics: Location, intensity, quality, aggravating/relieving factors, using a pain scale.
2. Monitor vital signs: Pain can elevate heart rate and blood pressure.
3. Assess incision sites: Rule out infection as a cause of increased pain.

Interventions:

1. Administer analgesics as prescribed: Provide timely and adequate pain medication.
2. Non-pharmacological pain relief: Positioning, splinting, relaxation techniques, distraction.
3. Patient education: Teach about pain management options and self-management strategies.
4. Encourage rest and comfort measures: Promote restful environment.

Risk for Infection Post-CABG

Nursing Diagnosis: Risk for Infection related to surgical incision, invasive procedures, and compromised immune status post-surgery.

Related to:

• Surgical incision (chest, leg if vein graft)
• Invasive lines and tubes (IVs, chest tubes, urinary catheter)
• Compromised immune system post-surgery

As evidenced by:

Risk diagnosis – no “as evidenced by” criteria. Focus is on risk factors.

Expected outcomes:

• Patient will remain free from surgical site infection, pneumonia, and other post-operative infections.
• Patient will demonstrate understanding of infection prevention measures.
• Incision sites will remain clean, dry, and without signs of infection.

Assessment:

1. Monitor vital signs: Fever is a key sign of infection.
2. Assess incision sites: Daily assessment for redness, drainage, warmth, swelling, pain.
3. Monitor WBC count: Elevated WBC can indicate infection.
4. Assess respiratory status: Auscultate lungs for signs of pneumonia.

Interventions:

1. Meticulous wound care: Follow sterile technique for dressing changes.
2. Hand hygiene: Strict hand hygiene for healthcare providers, patient, and visitors.
3. Monitor invasive lines and tubes: Maintain sterile insertion sites, follow protocols for line care.
4. Encourage deep breathing and coughing exercises: Prevent respiratory infections.
5. Administer prophylactic antibiotics: As prescribed pre- and post-operatively.
6. Patient education: Educate on signs and symptoms of infection and reporting them.

Ineffective Airway Clearance Post-CABG

Nursing Diagnosis: Ineffective Airway Clearance related to pain, effects of anesthesia, and decreased mobility post-CABG.

Related to:

• Pain from incision
• Effects of anesthesia and sedation
• Decreased mobility and activity post-surgery
• Increased secretions

As evidenced by:

• Adventitious breath sounds (crackles, wheezes)
• Ineffective cough
• Dyspnea
• Decreased oxygen saturation
• Increased respiratory rate

Expected outcomes:

• Patient will maintain clear breath sounds bilaterally.
• Patient will demonstrate effective coughing and deep breathing techniques.
• Patient will maintain oxygen saturation within acceptable limits.

Assessment:

1. Auscultate breath sounds: Assess for adventitious sounds.
2. Assess cough effectiveness: Note strength and effectiveness of cough.
3. Monitor respiratory rate, depth, and oxygen saturation.
4. Assess for signs of respiratory distress.

Interventions:

1. Encourage deep breathing and coughing exercises: Regularly, every 1-2 hours while awake.
2. Incentive spirometry: Encourage use every 1-2 hours while awake.
3. Pain management: Ensure adequate pain control to facilitate deep breathing and coughing.
4. Positioning: Elevate head of bed to promote lung expansion.
5. Suctioning: Perform tracheal suctioning as needed to remove secretions.
6. Humidified oxygen: If ordered, to help loosen secretions.
7. Early mobilization: As tolerated, to improve respiratory function.

These nursing diagnoses and care plan components provide a framework for delivering comprehensive nursing care to patients post-CABG. Individualized care plans should be developed based on each patient’s specific needs and assessment findings. Consistent monitoring, timely interventions, and patient education are crucial for optimal recovery and long-term outcomes after CABG surgery.

References

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