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Coronary Artery Bypass Grafting (CABG)

A clinical study on coronary artery bypass grafting, at AKUH, Pakistan.

Ahmad Yar Baig

on 5 April 2015

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Transcript of Coronary Artery Bypass Grafting (CABG)

Coronary Artery
Bypass Graft

A Clinical Case Study
Mr. X.Y.Z, 67 yr Male
MR# 267-62-80
The coronary arteries are bypassed by either the patient's own venous/ arterial vessels or a synthetic graft.

Most commonly used vessels:
-internal mammary artery (IMA)
-saphenous vein
-radial artery
Candidates for Surgery
Angina with > 50% occlusion of left main coronary artery that cannot be stented
Unstable angina with severe 2 vessel, moderate 3 vessel, or small vessel disease that cannot be stented
Ischemia with heart failure
Valvular disease
Coronary vessels unsuitable for PCTA(stenting)
Before the grafting procedure begins, cardiac arrest is induced and cardiopulmonary bypass (CPB) is used to provide oxygenation, circulation to the body. After the grafts are placed, they are observed for patency and leakage, and the patient can then be weaned off CPB.
Research/ CABG
Who are ....
We ?
-incidence of death and mycardial infarction was identical at 10%

-30% of patients that received PCI required additional revascularization
-8 of which underwent a CABG

-After 10 years, 93% of subjects (from either group) were asymptomatic. The other 7% experienced mild angina.

Patients have a significantly higher
survival rate with CABG than PTCA
Increased age associated with early death

-Serum lipids
Abnormally high levels will negatively affect
CABG and can lead to vein graft obstruction
10 year randomized trial with 123 subjects
A review of clinical trials by a cardiac surgical nurse specialist
-Preoperative education assists with recover, increases patient contentment, and decreases postoperative complications

-Educate at time of lowest anxiety: 5-14 days pre-op.

-Other research confirms the correlation among postoperative expectations, anxiety, and depression
Longitudinal study reviewing expectations, anxiety, depression, and physical health status in open-heart surgery patients.
Chunta, K.S. (2009). Expectations, anxiety, depression, and physical health status as predictors of recovery in open-heart surgery patients. Journal of Cardiovascular Nursing, Vol. 24 (6), 454-464.

Goy, J.J., Kaufmann, U., Hurni, M. Cook, S., Versaci, F., Ruchat, P., Bertel, O., Pieper, M., Meier, B., Chiarello, L., Eeckhout, E. (2008). Journal of the American College of Cardiology, Vol. 52 (10), 815-817.

Ignatavicius, D. D., & Workman, M. L. (2010). Medical-surgical nursing: patient- centered collaborative care (6th ed.). St. Louis, Missouri: Saunders Elsevier.

Martin, C.G. & Turkelson, S.L. (2006). Nursing care of the patient undergoing coronary artery bypass grafting. Journal of Cardiovascular Nursing, Vol. 21 (2), 109-117.

Webter, M.M. (2000). Surgical management of unstable angina and symptomatic coronary artery disease. Journal of Cardiovascular Nursing, Vol 15 (1), 27-42.
Risk factors play role in treatment choice:
-Diabetes Mellitus
following CABG
Group Members:

Ahmed Yar Baig (503265)
Nida Feroz (502660)
Asma Sultan (50....)
Saira Bano(504948)
Anusha Mansoor (502379)
Veena Alam (504177)
Tabassum Sardar (503793)

• Pain over the chest that travels to the arm
• A burning sensation in the chest
• Shortness of breath,
• irregular heartbeat,
• dizziness,
• sweating,
• fatigue
• Nausea
• Weakness
• tiredness
Potassium 20mEq
Heprin 25000 units
Sodium bi carbonate 20 ml
Atracurium besylate 25mg/ 2.5 ml
Vancomycin 500 mg QD
Imipenum 5 mg Q6H
Fentanyl 0.25mg
Tramadol 100mg
Propofol 200mg
Glyceryl trinitrate 50mg
Lipiget 10mg
Metoclopamide 10mg Q8H
Fentanyl citrate 500mcg/10ml - Anesthesia
Phenylephrine 10mg/ml - Decongestant
Normal saline 1000ml/bag - Electrolyte
Papavarine - 50mg/2ml – vasodilator
Left Main Coronary Artery 70-80%
Left Anterior Descending Artery 80%
Circumflex Artery : Total

Impaired gas exchange related to inability to breath effectively secondary to pulmonary edema andatelectasis as evidenced by oxygen saturation i.e. 86%
Decreased cardiac output related to alteration in electrical activity i.e. tachycardia secondary to surgical procedure as evidenced by heart rate of 120 beats per min.
Acute chest pain related to tissue trauma secondary to surgical procedure, CABG as evidenced by patient pain scale of 08
Fluid volume excess related to impaired venous return secondary to surgical procedure as evidenced by shortness of breath due to pulmonary edema.
Electrolyte imbalance i.e.
hypokalemia related to
High risk for infection i.e.
Presenting Complain: Chest pain 5-7 years
History of presenting complain :
According to the attendant, the patient was in his usual state of health 5-7 years back.
He had chest pain which was mild but since 2-3 months the pain increased in severity.
The pain occur only on exertion which is relived by rest.
He got angiography done that revealed 3VCAD on 19th february 2015.
Platelet Count


Potassium Graph

Coronary Artery Disease:

The coronary arteries supply blood to the heart muscle itself.
Damage to or blockage, can result in injury to the heart.
Normally, blood flows unimpeded
cholesterol plaque can build-up narrowing the available pathway through which blood can flow.

Clotted blood, transverse the blood vessel
Artery, tortuous and too narrow, may become completely constricted or blocked-off.
The blocked artery results in a lack of oxygen, or ischemia, to the part of the heart muscle that the artery supplies.
The result is a heart failure or myocardial infarction.

Pre Operative:
Intra Operative:
Post Operative:
What we are ...
Presenting .. ?
Overview of demographic data of Case
(From admission to OR)
Interview, History taking
Assessment, Medical interventions
Teaching needs, Informal teaching
Lab Tests
(Inside OR)
(exit from OR to Discharge)
Diagnosis, Surgical procedure
(A&P, Patho and Pharma)
Role of a student nurse in OR
Complications and Problems identification
Medical management
Nursing managent and Interventions
Teaching Plans, Discharge Teaching

Discharge Plans
Summary/ Review
Skin and wound Assessment : Using mirror and Demonstration on hand.
Substance Abuse : Handmade pamphlet and posters.
Diet After Discharge : Pamphlets ( Aku, Handmade), collaboratly discussed with family and planned his diet accordingly.
Medication (indications and side effects) : By writing them down on the medication cover.
Hypertension : By making handmade brochures
Activity after discharge: By making handmade pamphlets
Constipation: Provided ispaghol and made brochures
Shortness of Breath: Taught deep breadth and coughing excercises and taught spirometery and peek flow meter as well.
Epinephrine : Prevent cardaic arrest and hypotension thus increases heart rate

Papaverine HCl : Relief of myocardial ischemia associated with arrhythmias.

He is living in pacca house. And takes all the minor and major decision of their family being head of the family.

10 years back, His wife passed away.

His religious practices are impaired due to pain and hospitalization. Therefore he needs to offer tasbeeh to get self satisfaction
Role Relationship Pattern
At home he used to sleep 6-7 hours and in hospital he sleeps 5-6 hours due to noise disturbance and pain.

He was having high self steem but due to pain and hospitalization his emotional status was impaired.

He is a smoker since 50 years. He copes up with problems by discussing them with his sons and daughters in law.

Sleep Rest Pattern
His GCS was 11/15. Moreover had acute chest pain which was throbbing due to chest tubes and post surgery fatigue. Paracetamol and Tramadol are prescribed.

He is on total parental nutrition which was at the rate of 75ml/hr

Foleys attached and hasn’t passed stool since operative day. And was on diuretic therapy ( Furosmide)
Cognitive/Perception pattern

Rhytm=Irregular, Rate=29 and was taking deep breaths. Chest expansion=Bilaterally unequal. Moreover while auscultating lung, we heard crackles sound. Cough was productive with thick secretions. BiPAP attached, 2 chest tubes intact on gravity suction. Nebs of Ipratopium bromide, Alprastadil, N/S were given to patient as prescribed.

B.P was 90/64 while heart rate of 122 with irregular rhytm. Due to presence of pulmonary edema. Amiodarone, Glyceral trinitrate and Valsartan were given to patient as per ordered.

He was active at home while in hospital he is on complete bed rest. Fot that he was having vitamin multiples.

Impaired physical activity, Decreased cardiac output and Ineffective breathing pattern.

Activity Exercise Pattern

Patient was having hypertension as a co morbid therefore he was having certain hypertensive medication like (Norvasc, Eustac, Ascard,Rosubin).

He was having lack of knowledge about disease and procedure
Knowledge deficit related to disease process and management secondary to CABG as evidenced by patient verbalization “ I am here for CABG but don’t know what it actually is and how will I cope up after the procedure.” (FHP)
Health Perception
Patient maintained adequate fluid volume and electrolyte balance (goal met)
Patient was free from edema and was having clear lungs (goal met)

Monitor lab reports (plasma osmolality plasma sodium level urine osmolality HCT level and bun level,
Restrict sodium and water intake and suggest alternative.
Assess signs of overload give ice chips and cold fluid.
Avoid long standing sit with leg elevation
Frequent oral care
Reduce constrictions of vessels
Provide adequate activity and position change q4hr,
Monitor input and output closely
Assess for crackles in lungs, changes in respiration pattern shortness of breathe and orthopnea.
By the end of the shift patient will maintain adequate fluid volume electrolyte balance and vital signs. (short term goal)
By the end of hospitalization patient will be free from edema and will have clear lungs sound (long term goal)
Fluid volume excess
Patient maintained vital sign and mental status within normal range. (goal met)
Patient reported decrease episode of angina and was free from arrhythmia. (goal met)

Assess patient GCS level per shift.
Assess quality of all peripheral pulse q4hr.
Assess blood pressure every q4hr
Auscultate for heart sounds and breathe sounds q4hr.
Perform ECG.
Monitor ECG pattern for cardiac arrhythmias.
Asses cardiac markers and ABGs according to physician order.
Assess skin colour and capillary refill every q4hr.
Measure urine output.
Administer supplemental oxygen.
Give drugs to maintain blood pressure per doctors order.


By the end of the shift patient will be able o maintain vital signs within normal range and unusual level of mental status. (short term goals)
By the end of hospitalization patient will report decrease episode of angina and arrthymias. (long term goals)

Decrease cardiac output
Patients bed sore reduce from 2 degree to 1 degree. (goal met)
Family member understanding and verbalizing to do ulcer care and dressing.(goal met)


Assess between folds of the skin remove anti embolic stoking's and devices and use a mirror to see the heals.
Also assess under oxygen tubing especially on the ears and the check, beneath splints and under medical devices.
Note objective data of pressure ulcers (stage, length, width, depth, wound bed, appearance, drainage and condition of ulcer.


Patient wound will be kept clean and free from any further infections by the end of the shift. (short term goal)
Patient will not have any further skin breakdown during the hospitalization stay. (long term goal)
Caregiver will demonstrate understanding and skill in care of wound by the end of the hospitalization (long term goal)

Impaired skin integrity

Assess respiratory rate, rhythem, depth, use of assesorry muscles q4hr
Auscultate breathing sound q4hrly
Keep patient in high fowler position.
Attach bipap 4hr on and 2 hr off.
Provide humidified oxygen air.
Assess patient in deep breathing and coughing exercise q2hr
Provide steam inhalation.
Monitor chest x rays and ABG’s
Administer nebs as prescribe.

By the end of the shift patient will be able to maintain oxygen saturation of 95% using bipap. (short term goal)
By the end of the hospitalization patient will breathe spontaneously without using any device. (long term goal)

Ineffective breathing pattern
Vital signs will be in normal range.
Isolation techniques and precaution will be maintained as needed.


Assess and note risk factor for occurrence and worsening of infection.
Assess all invasive lines for redness inflammation drainage and tenderness.
Check temperature in every shift
Assess wound side every 24 hrs. and during dressing changes and document abnormal findings.
Send blood sputum tips of invasive lines and other body fluids for Cs when ordered.
Administer antibiotics as ordered by doctors and monitor its effectiveness.
Observe colour and clarity of urine and report unusual observations.
Use aseptic technique during dressing change of wounds or IV lines and during invasive procedures.


By the end of shift patient vital signs would be with in normal range. (short term)
Patient will be free from infectious processes by the end of discharge. (long term)
Staff will demonstrate universal precautions all the time. (short term)
By the end of the shift patient will not develop nosocomial infection. (long term)
By the end of the hospitalization patient will be free from infectious disorders. (long term)

Risk of infection
Goal met as patient pain scale is 5/10 by the end of shift.
Goal met as patient pain score is 2/10 bt the end of the hospitalization.


Acknowledge the presence of pain level
Assess pain level so that its management can be adjusted
Administer pain killer and muscle relaxant medication to relief pain
Teach patient to use non pharmacological method to control pain such as deep breathing or slow rhythmic breathing massage therapy
To provide pt. with opportunities rest during the day and period of uninterrupted sleep at night

(short term) by the end of the shift patient will relate pain as 5/10.
(long term) by the end of the hospitalization patient will rate pain as 2/10.
Invasive line insertion
Monitor for specific risks associated with use of anesthesia, analgesia, and amnesia
Monitor cardiovascular function as inhalation agents can be cardiodepressive
Monitor the site of endotracheal intubation for patency
Monitor cardiopulmonary bypass (CPB) machine if used, cannulation sites are prone to occlusion, hemorrhage, and infection
Rewarming of the body
(Martin & Turkelson, 2006)
Intra operative Care for CABG
Skin and wound management
Substance abuse (Smoking)
Diet plan after discharge
Medication (indications and side effects)
Activity after discharge
Shortness of Breath

Identified Teaching Needs

As patient maintain oxygen saturation of 95% by the end of the shift (goal met)
As patient breathe spontaneously without using any device (goal met)

Lack of knowledge
Medical intervention

Cefazolin Na 1000mg - Prophylactic
Valsartan 40 mg - Anti-hypertensive
Rosuvastatin 20mg – choletrol
Metazolam 7.5mg -Anxiety
Alprazolam 0.5 mg –Anxiety
Teaching (Informal)
Surgical procedure
Post OP
Intra OP
Diagnostic Procedure
Surgical Procedure
Care during procedure
Decision .....
Saphenous vein
Blocked artery
Intra OP Medications
In the name of Allah Almighty, the creator and sustainer of whole universe, the King of kings, Omni-potent and Omni-present.
Post-OP Medication
Sign and symptoms:
Medical management
Nursing interventions

Constipation related to decrease response to urge to defecate secondary to surgical procedure as evidenced by I/O i.e. no stool passed since 2 days
Impaired skin integrity related to pressure ulcers secondary to immobility as evidenced by 2 degree bedsore on sacrum region.
Self care deficit related to post operative fatigue secondary to CABG as evidenced by patient verbalizing “ I am not feeling good about myself as I am not able to perform hygiene care”
Knowledge deficit related to disease process and management secondary to CABG as evidenced by patient verbalization “ I am here for CABG but don’t know what it actually is and how will I cope up after the procedure.”

Nursing Interventions
Value Belief pattern
Sexuality And Reproductive Pattern
Coping –Stress Tolerance Pattern
Self Perception Self Concept Pattern
Elimination Pattern
Nutrition and Metabolic pattern
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