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Nursing Care of the Telemetry Patient ©TCHP Education Consortium, February 2002, Rev. October 21051

Paula Tymesen, RN

American Heart Association How many CABG’s performed in U.S.

annually? How many are men and how many are

women? What percentage experience chest pain relief? How many die during surgery? What percentage of pts experience a recurrence

of angina at the 10 year mark?

Usually admitted day before surgery

Labs (cbc, electrolytes) Why?

CXR – Why?

EKG UA/UC – Why? Consent

Question/Answer session

Written material and videos on:• Post op breathing• Pain management• Diet/nutrition• Emotional/psychological

Anti microbial

scrub night

before:

• Hibiclens/Cida-Stat/Chloroprep

• Scrub neck to hips and both legs and arms

• 5-10 min. x 2 evening before, 4 hours apart

• Rinse well• Clean pajamas after

each scrub• Use regular shampoo• No lotions,

deodorants, oils, powder, or perfumes.

Sternotomy

Harvest Vessel

Pump Oxygenator

Incision below the blockage

Pacing Electrodes

Chest Tubes

Sternum Wired

Minimally Invasive Direct Coronary Artery Bypass: alternative to

CABG

Criteria

Benefits/down side

Outcomes



“ET” placed under

anesthesia

Tube out 4-6 hours

after surgery

Sore throat for a few

days

Cordis into intra-jugular

Changed every 3 days

Removed prior to leaving

intensive care to surgical

floor.

Pressure dressing, leave on for 24 hours

Initiate peripheral IV

before sending to surgical

floor.

Pre-existing patient history• Heart• Lungs• Renal/Uro• GI• Diabetes• Drugs• ETOH/smoker/addictions• Living conditions

Sternum

Chest Tube

Donor Site

Use of arms

Activity Limitations

Transferring/Ambulation

O2 Sats – is that the whole story?

INCENTIVE SPIROMETER – Not just a toy

ACAPELLA/METANEB

HUMIDITY WITH O2

NEBS/INHALERS/BIPAP



Diminished

Rhonchi

Wheezy

Absent

Crackles

Stridor

Who gets poked, why?

How often?

How much glucose

control is necessary?

NURSES : What’s your

main priority after

CABG?

Not just BP, HR, RR,

Temp, Pain

Cardiac Output-

what to look for – subtle

signs

↑Temp – think activity or infection

↑ HR – Heart working too hard, why?

↓ HR – Think meds

↑ RR – Smoker?, sudden or gradual onset?

↓ RR – Think meds again…

↑ BP – Fluid status? Pain? Meds?

↓ BP – Fluid status? Meds?

Peripheral• Careful I&O’s, Daily

weights• Lower Extremity

Elevation• Diurese

Lungs – fluid overload –• Pulmonary

congestion/edema• CXR• Careful I&O’s, fluid

restriction• Weight comparisons• Diurese

Dysrhythmia – Most Common• ATRIAL FIBRILLATION



30-60% CABG pts have pulmonary dysfunction and hypoxemia after surgery – why? Symptoms?

Risk factors

Atelectasis

Pleural effusion

Prevention/Nursing Actions

Post Op Delerium

General Confusion/Memory

Emotional Issues

Besides keeping patient

comfortable…

Pain Meds

Other/Holistic

Oversedation

Bleeding can have

many causes

Hematocrit <26%

DVT/Pulmembolism –prevention

Valve Patient

Approx 8% have renal dysfunction after CABG

Predictors

Monitor: Wt, UO, VS, Labs, Cardiac function

Anorexia and nausea are the most common

non-threatening GI

issues after CABG

Most common: Upper GI

Bleed, 1-2% affected

Monitoring Tests



Purpose

More than one?!

Gravity or suction?

Pain

Drainage

Removal

Complications

SUDDEN DECREASE

Clot? Occlusion? Pinched? What should

the nurse do? Are there

signs/symptoms in patient? What are

they?

TENSION PNEUMOTHORAX

Emergency!!! What is it?

What are the symptoms?

What is the main concern?

What to do?

Pacer wires loosely sutured to epicardiumand brought through

the skin; why?

Usually are capped individually inside

a tube which is taped down with

occlusive dsg underneath heavy

abd dsg.

What should you NEVER do with exposed pacer

wires and what could happen if

you do?

•Amount – Wt.-dependent: 1/2cc/kg /hr.•Ex: 180 lbs x 2.2 = 81.8kg x .5 = 40.9cc/hr

avg.•Color- Possible dehydration if concentrated•Odor – infection/too

concentrated/dehydration•Sediment/blood – cloudy? UTI: UA/UC•Blood? Possible nick with placement unless

continued bloody presence.•Check for pinched tubing.

Assess

Usually removed when chest tubes are out.

What might be a typical order after foley removal?

Prostate problems?Hypertrophyvs. Hyperplagia. Finasteride vs. Terazosin. NOTE: Finasteride is

also a hair growth stimulant!

PatientSituationREPORT FROM OVERNIGHT NURSE:

CABG POD#2CT’s and foley removedNSRRR 18No MIVHR mid 90’sSats 90% on 3L O2BP 95/74UO over 12 hrs: 200cc, clear, amberIntake: sips, slept through nightPain 6/10, Percocet x 2 tabs once + Visteral, 50mg

As you walk out of report, you notice an irregular rhythm and go to check on pt. Pt is just waking and appears to be slightly confused an unable to answer questions fully. He is diaphoretic and you are unable to get pulse ox to register. Suddenly hi HR drops to 20 and you notice his eyes gazing upward. What do you do? How could this have been prevented?



ATELECTASIS

What is it?

What are the symptoms/Tx’s?

What can it lead to?

A-FIB

What is it?

What are the symptoms/Tx’s?

Complications?

Anti arrhythmic drug

Infusion usually 24 hours

Dosage

Monitor

Goal: conversion to NSR

• CAUSE• WHAT IT IS• MANIFESTATIONS• Can lead to pericardial

effusion /Cardiac Tamponade.

Pericarditis

An accumulation of excess fluid in the pericardium.

COMP-RESSION

SLOW ONSET

QUICK ONSET



www. Finlay-online.com/albarranschoolofmedicine

Catecholeminesurge

FluidImbalance

Cardioplegia

“Pump Head” hmmm…

Nml: 3.5-5.2 Panic: >8.0 & <2.5

Many roles

Cardiac role: Along with Ca and Mg,

potassium controls rate and force of contraction and

thus the CO.

Usually replaced <3.5

Per sliding scale

Most common cause of depletion?

Manifestations

Prevention

//lifeinthefastlane.com/ecg-library/basics/hypokalaemia/

Usually treated >

5.0

Causes

Manifestations

Prevention



Normal Levels 1.8

- 2.6

Panic Levels <1.2 &

>5.0

Many Roles

Cardiac Roles

Usually Treated <2.4

Causes

Manifestations

Treatment http://medicases.blogspot.com/2010/10/ecg-abnormalitiespart-06.html

>5.0 - >10

Causes

Manifestations

Treatment

Wide variations in serum Ca+ not

typical in CABG patients. So why do

we care?

MusclePhosphorous



Goal

Prevention: Constipation

& Ileus

Don’t Strain!

Causes

Magnesium Citrate prior to surgery

Bisocodylsuppository MOM

Prune juiceSenokot

ColacePsyllium

Polyethylene

glycol

How do these work? Why is it so important to have

a bowel movement after surgery?

• Bisocodyl & Sennosides, Senna, ExLax, Correctol, Dulcolax

• ACTION: <12 hrsStimulants

• Mag Citrate, MOM, Fleets, Miralax, Go-Lytely• ACTION: 15 min – 3 hrsSaline/Osmotics

• Colace, Mineral Oi• ACTION: 8-72 hrsl

Stool Softener/Lubricants

• Metmucil, Citrucel, fiberCon• ACTION: <24 hrsBulk Forming

What type of abdominal

symptoms would Metamucil (bulk-

forming) be contraindicated

in administering?

Why would a Magnesium-containing product be

contraindicated for renal

insufficiency?

Patient SituationCABG POD#3NSRBP 135/82HR upper 70’sRR 16Sats 93%, RANon productive cough, hoarsenessLS clear/diminished bilatNo MIVUO overnight = 150cc+ flatus, last BM preopPain 2/10 tolerableTolerating reg dietMod bilat edema LEEcchymosis at graft site L med knee

You answer his call light and he c/o chest pain 8/10. States he does not feel it is incisional pain. He’s agitated, tachypnic.

VS: HR 120, heart sounds distant/muffled. There is a change in BP from his baseline to 100/90. Monitor shows ST elevation. You call for EKG machine & Rapid Response. Pt sits up and leans forward whereupon he states the pain just went away.

Day 1-2

Day 2

Day 3Day 4

Day 5



Discharge planning: Team

Approach

When to contact

hospital/doctor

What to expect/what’s

normal

Lifestyle change

Activity progression

Incisonal care

Patient SituationCABG POD#3L-Side atelectasis and smpleural effusion.Electrolytes within normal levels.Edematous hands & feet.Hx of HTN, DMII & quit smoking upon arrival to surgery.

Yesterday, BP was 89/75, BB held, PO intake poor, given IV bolus NS 1000cc & reestablish MIV NS@ 125ml/hr which were d/c’d sometime on night shift.

This morning, SBP = 148. scheduled BB, HCTZ, & Lisinopril given. You administer new orders for IV Lasix, 20mg, t.i.d. to diurese.

UOP on days = 1500cc. Later on eve shift, pt’s rhythm shows ST depression, presence of U wave with PVC’s. HR 48. What do you suspect? What labs should you check?

Diabetes & Hypertension

in Renal Failure

• Small blood vessels in kidneys damaged from diabetes

• Sodium retention and excess fluid volume

• Atherosclerotic vascular disease/left ventricular hypertrophy and CHF/fluid overload.• CHF>>>Pulmonary

Edema • MI & stroke.

Cardiac arrythmia’s Electrolyte Imbalances/correction

Stroke Major limitation of a standard ECG is that it may not detect transient arrhythmias Cardiac monitoring for 24 hours continuous with acute stroke. ECG abnormalities observed in 60% of patients with cerebral infarct. 3-month mortality was predicted by A-fib, AV Block, ST changes, & inverted T

waves regardless of stroke severity, disability, or age.

750,000 strokes/year in U.S.15% are cardioembolic

A-fib Cardiac Failure M.I. Other:

Prosthetic heart valve Interatrial septal defect Endocarditis Myocardiopathy Mitral rheumatic stenosis



Secondary prevention with anticoagulants should be started immediately if possible in patients at high risk for recurrent cardioembolic stroke in which contraindications, such as falls, poor compliance, uncontrolled epilepsy or gastrointestinal bleeding are absent.

Source: AHA

Alcoholic Post Necrotic

Biliary Cardiac

4 types of cirrhosis all leading to liver

failure

CHF Hepat-omegaly

Liver Cell

DeathFibrosis Cirrhosis

Cardiac/ Cirrhosis

Right- sided heart failure• Cor Pulmonale• Constrictive Pericarditis• Tricuspid Insufficiency

Fat Embolism Syndrome

• What is it?• What is typical

outcome?• Who develops it?• 2 Theories



Manifestations

• Symptoms occur usually 24-48 hrs after injury

• ARDS symptoms >>>>>Hypoxemia>>>>>>>>>CNS involvement

• Labs: fat cells in blood, urine, sputum

• ST changes on ECG

Collaborative Care•Telemetry•Immobilize•Manage symptoms•Fluids•Cough, deep breathe•O2 for Hypoxia•Possible Intubation or Intermittent Pos Pressure

Breathing if PaO2 cannot be obtained with supplemental O2.

Resources and References for TCHP Class: Foundations of Telemetry: Post Op Management of the Cardiac Patient & Nursing Care of Telemtry Patients: Renal, Neuro, GI, Ortho

American Heart Association, 2015: http://www.heart.org/HEARTORG/American Lung : http://www.lung.org/?referrer=https://www.google.com/Mayo Clinic: http://www. mayoclinic.orgWebMd: http://www.webmd.com/NIH: https://www.nih.gov/WHO: http://www.who.int/en/Centers for Disease Control: http://www.cdc.gov/American Chronic Pain Association: https://theacpa.org/default.aspxNational Kidney Foundation: www.kidney.org/search-results?solr-keywords=kidney+cardiac

National Institute of Diabetes and Digestive and Kidney diseases: www.niddk.nih.gov/American College of Gastroenterology http://gi.org

American Gastroenterological Association: http://www.gastro.org/American Urological Association: https://www.auanet.org/http://www.drugguide.com/ddo/index/Davis-Drug-Guide/All_Entries/AACLS: American Heart Association, Advanced Cardiovascular Life Support, Provider Manual,

Professional, 2011Fischbach Edition 7, A Manual of Laboratory and Dignostic TestsNeurological Institute – Cleveland Clinic: http://my.clevelandclinic.org/services/neurological_institute

National Institute of Neurological Disorders and Stroke: http://www.ninds.nih.gov/index.htmJournal of Emergencies, Trauma and Shock http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700578/

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