Coronary Artery Bypass Graft (CABG) surgery is a critical intervention for patients with severe coronary artery disease (CAD), aiming to restore blood flow to the heart muscle. Post-operative nursing care is paramount to ensure patient recovery and prevent complications. Accurate nursing diagnoses are the cornerstone of effective care planning, guiding interventions and promoting optimal patient outcomes after CABG surgery. This article provides a comprehensive guide to common nursing diagnoses relevant to patients recovering from CABG surgery, enhancing your understanding of post-operative care.
Common Nursing Diagnoses Following CABG Surgery
Following CABG surgery, patients require meticulous nursing care to address various physiological and psychological challenges. Several nursing diagnoses are commonly identified in the post-operative period. These diagnoses focus on potential and actual problems related to the surgical procedure, anesthesia, and pre-existing conditions. Understanding these diagnoses is crucial for nurses to deliver targeted and effective care.
Acute Pain
Post-operative pain is a significant concern following CABG surgery. The surgical incision, chest tubes, and manipulation of tissues during surgery contribute to acute pain.
Nursing Diagnosis: Acute Pain
Related to:
- Surgical incision (sternotomy, graft sites)
- Tissue trauma during surgery
- Chest tubes
- Musculoskeletal discomfort from positioning during surgery
As evidenced by:
- Verbal reports of pain (chest, incision sites, back, shoulders)
- Pain scores (using pain scales)
- Guarding behavior
- Facial grimacing
- Increased heart rate, blood pressure, and respiratory rate
- Restlessness and anxiety
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., use of analgesics, relaxation techniques).
- Patient will participate in post-operative activities (e.g., coughing, deep breathing, ambulation) with manageable pain.
Assessment:
- Assess pain characteristics: Utilize pain assessment tools (e.g., numerical rating scale, visual analog scale) to evaluate pain intensity, quality, location, and aggravating/relieving factors. Assess pain at rest and with activity.
- Monitor vital signs: Changes in vital signs (increased heart rate, blood pressure, respiratory rate) can indicate pain, although these can also be related to other post-operative conditions.
- Assess incision sites and chest tube sites: Observe for signs of inflammation, infection, or drainage, which can contribute to pain.
- Evaluate non-verbal cues of pain: Observe for facial expressions, body posture, restlessness, and reluctance to move, which can indicate pain, especially in patients who have difficulty verbalizing.
Interventions:
- Administer analgesics as prescribed: Provide pain medications (opioids, non-opioids, adjuvant analgesics) proactively and as needed, considering the patient’s pain level and medical history. Utilize multimodal analgesia approaches.
- Implement non-pharmacological pain management techniques: Encourage relaxation techniques (deep breathing, guided imagery), positioning for comfort, and application of heat or cold as appropriate.
- Educate patient on pain management: Teach the patient about the pain scale, medication options, and non-pharmacological methods. Encourage patient to report pain promptly.
- Optimize patient positioning: Assist the patient to find comfortable positions that minimize strain on the incision and chest tube sites. Support with pillows as needed.
- Splint incision during coughing and deep breathing: Instruct the patient to splint the sternal incision with a pillow during coughing and deep breathing exercises to reduce pain and promote effective airway clearance.
Risk for Infection
CABG surgery, like any surgical procedure, carries a risk of infection. Sternotomy site infections, mediastinitis, pneumonia, and surgical site infections at graft harvest sites are potential complications.
Nursing Diagnosis: Risk for Infection
Related to:
- Surgical incision (sternotomy, graft sites)
- Invasive procedures (chest tubes, central lines, urinary catheter)
- Compromised immune status (due to surgery, anesthesia, pre-existing conditions)
- Impaired skin integrity
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and the goal of nursing interventions is aimed at prevention.
Expected outcomes:
- Patient will remain free from surgical site infection and other post-operative infections.
- Patient will demonstrate understanding of infection prevention measures.
- Patient will maintain normal temperature and white blood cell count within acceptable limits.
Assessment:
- Monitor vital signs: Elevated temperature (fever) and increased heart rate can be early signs of infection.
- Assess surgical incision sites and chest tube sites daily: Observe for redness, warmth, swelling, drainage (purulent, foul-smelling), and increased pain.
- Monitor white blood cell count (WBC): Elevated WBC can indicate infection, although it can also be elevated due to the surgical stress response.
- Assess respiratory status: Auscultate lung sounds for adventitious sounds (crackles, wheezes) that may indicate pneumonia. Monitor sputum characteristics.
- Review patient’s risk factors: Identify pre-existing conditions (diabetes, obesity, COPD, immunocompromised state) that increase infection risk.
Interventions:
- Maintain aseptic technique: Adhere to strict aseptic technique during dressing changes, wound care, and invasive procedures (IV insertion, catheter care).
- Promote hand hygiene: Emphasize hand hygiene for healthcare providers, patients, and visitors.
- Ensure prophylactic antibiotics are administered as prescribed: Administer antibiotics as ordered pre-operatively and post-operatively to reduce surgical site infection risk.
- Encourage early ambulation and deep breathing exercises: Promote lung expansion and prevent pneumonia through early mobilization and respiratory exercises.
- Provide meticulous wound care: Cleanse and dress incision sites as per hospital protocol. Monitor for signs of infection with each dressing change.
- Optimize nutritional status: Adequate nutrition supports immune function and wound healing. Encourage a balanced diet rich in protein and vitamins.
- Educate patient on infection prevention: Instruct the patient on signs and symptoms of infection, importance of hand hygiene, and proper wound care at home.
Alt text: Cardiac catheterization procedure visualizing coronary arteries to assess for blockage, relevant to CABG surgery planning.
Decreased Cardiac Output
CABG surgery, while intended to improve cardiac output in the long term, can temporarily lead to decreased cardiac output in the immediate post-operative period. This can be due to myocardial dysfunction, arrhythmias, and fluid imbalances.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Myocardial ischemia or infarction during or post-surgery
- Arrhythmias (atrial fibrillation, bradycardia, tachycardia)
- Fluid and electrolyte imbalances
- Effects of anesthesia and medications
- Preload and afterload alterations
As evidenced by:
- Hypotension or hypertension
- Tachycardia or bradycardia
- Arrhythmias on ECG monitoring
- Decreased peripheral pulses
- Cool, clammy skin
- Decreased urine output
- Dyspnea, orthopnea
- Fatigue, weakness
- Chest pain or angina
- Changes in mental status (restlessness, confusion)
- Pulmonary congestion (crackles on auscultation)
- Edema
Expected outcomes:
- Patient will maintain adequate cardiac output as evidenced by stable vital signs (heart rate, blood pressure within patient-specific parameters), palpable peripheral pulses, warm and dry skin, adequate urine output, and absence of signs of heart failure.
- Patient will demonstrate tolerance to activity without symptoms of decreased cardiac output (dyspnea, chest pain, fatigue).
Assessment:
- Continuously monitor vital signs and ECG: Assess heart rate, rhythm, blood pressure, and ECG for arrhythmias and hemodynamic instability.
- Assess hemodynamic parameters: Monitor central venous pressure (CVP), pulmonary artery pressure (PAP), and cardiac output (if available) to assess fluid status and cardiac function.
- Assess peripheral circulation: Evaluate peripheral pulses (strength, equality), skin temperature, color, and capillary refill.
- Monitor urine output: Decreased urine output (<30 ml/hr) can indicate decreased renal perfusion secondary to decreased cardiac output.
- Auscultate heart and lung sounds: Assess for abnormal heart sounds (murmurs, gallops) and lung sounds (crackles, wheezes) indicative of heart failure or fluid overload.
- Assess for signs of decreased tissue perfusion: Evaluate for changes in mental status, chest pain, dyspnea, and fatigue.
Interventions:
- Administer medications as prescribed: Administer inotropic agents (e.g., dobutamine, milrinone) to improve contractility, antiarrhythmics to manage arrhythmias, antihypertensives or vasopressors to maintain blood pressure, and diuretics to manage fluid overload, as ordered.
- Manage fluid balance: Monitor fluid intake and output closely. Administer intravenous fluids and electrolytes as prescribed to optimize preload. Restrict fluids if signs of fluid overload are present.
- Optimize preload, afterload, and contractility: Collaborate with the physician to adjust medications and fluid management strategies to optimize hemodynamic parameters and cardiac output.
- Promote rest and reduce cardiac workload: Encourage rest periods and minimize unnecessary activities that increase cardiac demand.
- Monitor for and manage complications: Assess for and promptly report signs of heart failure, cardiogenic shock, and arrhythmias.
Impaired Gas Exchange
Anesthesia, pain, and immobility post-CABG surgery can contribute to impaired gas exchange and respiratory complications.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Effects of anesthesia
- Pain and restricted chest wall movement
- Atelectasis and pneumonia
- Decreased mobility and bed rest
- Potential for pulmonary edema
As evidenced by:
- Abnormal arterial blood gases (ABGs) – decreased PaO2, increased PaCO2
- Decreased oxygen saturation (SpO2 < 90%)
- Dyspnea, shortness of breath
- Increased respiratory rate
- Use of accessory muscles for breathing
- Cyanosis
- Restlessness, confusion
- Abnormal breath sounds (crackles, wheezes, diminished breath sounds)
Expected outcomes:
- Patient will maintain adequate gas exchange as evidenced by SpO2 ≥ 95% or patient’s baseline, PaO2 within normal limits, and absence of respiratory distress.
- Patient will demonstrate effective coughing and deep breathing techniques.
- Patient will have clear breath sounds.
Assessment:
- Monitor respiratory rate, depth, and effort: Assess for tachypnea, labored breathing, and use of accessory muscles.
- Auscultate lung sounds: Assess for adventitious breath sounds (crackles, wheezes, rhonchi) and diminished breath sounds.
- Monitor oxygen saturation (SpO2) continuously: Maintain SpO2 monitoring and report values below the patient’s target range.
- Assess arterial blood gases (ABGs): Obtain and analyze ABGs to evaluate oxygenation (PaO2) and ventilation (PaCO2) status.
- Assess cough and sputum: Evaluate the effectiveness of cough and characteristics of sputum (color, consistency, amount).
Interventions:
- Administer supplemental oxygen as prescribed: Provide oxygen therapy to maintain SpO2 within the desired range.
- Encourage coughing and deep breathing exercises: Instruct and assist the patient to perform coughing and deep breathing exercises regularly (every 1-2 hours while awake) to promote lung expansion and clear secretions.
- Position patient for optimal lung expansion: Elevate the head of bed to semi-Fowler’s or high-Fowler’s position to improve diaphragmatic excursion and lung expansion. Encourage turning and repositioning frequently.
- Incentive spirometry: Instruct and encourage the patient to use incentive spirometry to promote sustained lung inflation and prevent atelectasis.
- Administer medications as prescribed: Administer bronchodilators and mucolytics if ordered to improve airway clearance and ventilation.
- Monitor for and manage respiratory complications: Assess for signs of pneumonia, atelectasis, and pulmonary edema. Report changes in respiratory status promptly.
- Suction as needed: If the patient is unable to clear secretions effectively, perform nasotracheal or oropharyngeal suctioning as needed.
Risk for Bleeding
CABG surgery involves anticoagulation during the procedure and antiplatelet/anticoagulant therapy post-operatively, increasing the risk of bleeding.
Nursing Diagnosis: Risk for Bleeding
Related to:
- Surgical procedure and tissue trauma
- Anticoagulation therapy (intra-operative heparin, post-operative aspirin, clopidogrel, etc.)
- Chest tube drainage
- Potential for gastrointestinal bleeding (stress ulcers)
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and the goal of nursing interventions is aimed at prevention.
Expected outcomes:
- Patient will remain free from excessive bleeding.
- Patient will demonstrate understanding of bleeding precautions.
- Patient will have stable hemoglobin and hematocrit levels.
Assessment:
- Monitor vital signs: Hypotension and tachycardia can be signs of blood loss.
- Monitor chest tube drainage: Assess chest tube drainage for amount, color, and consistency. Report excessive or sudden increases in drainage, or bright red bleeding.
- Monitor incision sites and puncture sites: Observe for bleeding or hematoma formation at surgical incisions, graft harvest sites, and vascular access sites.
- Monitor laboratory values: Review hemoglobin, hematocrit, platelet count, and coagulation studies (PT/INR, aPTT) for trends and abnormalities.
- Assess for signs of internal bleeding: Monitor for abdominal distension, back pain, flank bruising, changes in mental status, and signs of hypovolemic shock.
Interventions:
- Monitor coagulation studies and adjust anticoagulation as ordered: Closely monitor PT/INR, aPTT, and platelet counts, and collaborate with the physician to adjust anticoagulant dosages as needed.
- Administer blood products as prescribed: Be prepared to administer blood transfusions or blood products if significant bleeding occurs.
- Apply pressure to bleeding sites: Apply direct pressure to any bleeding sites (incision, puncture sites) and notify the physician.
- Implement bleeding precautions:
- Use soft toothbrushes and electric razors.
- Avoid intramuscular injections if possible; use small gauge needles for subcutaneous injections and apply prolonged pressure.
- Prevent constipation and straining during bowel movements.
- Avoid activities that may cause trauma.
- Educate patient on bleeding precautions: Instruct the patient on signs and symptoms of bleeding and bleeding precautions to follow at home.
- Monitor for gastrointestinal bleeding: Administer proton pump inhibitors or H2 receptor antagonists as prescribed to prevent stress ulcers. Assess stool and emesis for occult or frank blood.
Anxiety
CABG surgery is a major life event that can evoke significant anxiety in patients and their families. Fear of the unknown, concerns about recovery, and changes in lifestyle contribute to anxiety.
Nursing Diagnosis: Anxiety
Related to:
- Fear of surgery and outcomes
- Uncertainty about prognosis and recovery
- Changes in health status and lifestyle
- Pain and discomfort
- Hospital environment and separation from home
As evidenced by:
- Verbalization of anxious feelings, worry, or fear
- Restlessness, irritability
- Insomnia or sleep disturbances
- Increased heart rate and respiratory rate
- Trembling, sweating
- Expressed concerns about finances, family, or lifestyle changes
Expected outcomes:
- Patient will verbalize a reduction in anxiety and demonstrate effective coping mechanisms.
- Patient will utilize relaxation techniques to manage anxiety.
- Patient will report feeling more informed and in control of their situation.
Assessment:
- Assess patient’s level of anxiety: Use anxiety assessment scales (e.g., GAD-7) or open-ended questions to evaluate the patient’s anxiety level and identify specific stressors.
- Observe for verbal and non-verbal cues of anxiety: Assess for restlessness, irritability, pacing, fidgeting, rapid speech, and expressions of worry or fear.
- Assess coping mechanisms: Determine the patient’s usual coping strategies and their effectiveness in managing current anxiety.
- Identify support systems: Assess the patient’s available social support network (family, friends, support groups).
Interventions:
- Provide emotional support and reassurance: Listen actively to the patient’s concerns and fears. Offer reassurance and a calm presence.
- Provide accurate and honest information: Explain procedures, treatments, and expected outcomes clearly and honestly. Address patient’s questions and concerns.
- Educate patient and family: Provide education about CABG surgery, post-operative care, recovery process, and lifestyle modifications. Involve family members in education and support.
- Encourage verbalization of feelings: Create a safe and supportive environment for the patient to express their feelings and fears.
- Teach relaxation techniques: Instruct the patient in relaxation techniques such as deep breathing exercises, guided imagery, and progressive muscle relaxation. Encourage regular practice.
- Facilitate access to support services: Connect the patient with social workers, chaplains, or support groups as needed.
- Administer anti-anxiety medications as prescribed: Administer anxiolytics as ordered to manage severe anxiety, especially in the immediate post-operative period.
Conclusion
Nursing diagnoses provide a framework for organizing and delivering comprehensive care to patients following CABG surgery. By recognizing and addressing these common diagnoses – Acute Pain, Risk for Infection, Decreased Cardiac Output, Impaired Gas Exchange, Risk for Bleeding, and Anxiety – nurses can significantly contribute to the patient’s recovery, prevent complications, and improve overall outcomes. Continuous assessment, timely interventions, and patient education are essential components of effective post-CABG nursing care.
Alt text: Telemetry monitoring showing ECG readout, essential for post-CABG patients to detect arrhythmias and cardiac changes.
