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Management and rehabilitation of a patient following bypass surgery

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Jillian Riley, MSc, BA (Hons), RN, RM.

Senior Lecturer, Thames Valley University, Royal Brompton Hospital

Philip Martin, a 49-year-old gardener, first presented to his GP with symptoms of mild heart failure, for which he was treated with diuretics and ACE inhibitors (Riley and Blue, 2001).

Philip Martin, a 49-year-old gardener, first presented to his GP with symptoms of mild heart failure, for which he was treated with diuretics and ACE inhibitors (Riley and Blue, 2001).

His medical history showed that he had at least three risk factors for coronary heart disease (CHD): he had smoked 40 cigarettes a day for more than 20 years and still did so, his total cholesterol level was 7.5mmol/l, and his father had died of a myocardial infarction aged 50 (Jairath, 1999). Twelve months later Mr Martin found his physical activity limited by angina, forcing him to stop work.

A coronary angiography showed that his left ventricular function was moderate. He had a total occlusion of his left anterior descending artery, a smaller obstruction to his right coronary artery and a severe stenosis of the main circumflex artery and one of its branches. Severe triple-vessel disease and impaired left ventricular function was diagnosed. As the atheromatous lesions were patchy, percutaneous coronary angioplasty was not a suitable treatment, so Mr Martin was referred for coronary artery bypass grafting.

While he waited three months for surgery, he attended classes for secondary prevention. Because he did not wish to stop smoking, he was advised to cut down. Closer to surgery he was taught deep-breathing exercises to reduce his risk of developing a postoperative chest infection.

He was encouraged to keep as active as possible, to take a short walk every day, and to use his glyceryl trinitrate spray effectively. His cholesterol level was elevated, so he was given dietary advice. Preparation for surgery was aimed at enhancing postoperative recovery and assisting with lifestyle changes to aid long-term outcome.

The bypass grafts were to be harvested from the saphenous vein of his left leg, and the left internal mammary artery was to be used to bypass the obstruction to the left anterior descending artery. The surgery was to be performed through a small medial incision and using heart stabilisers, to avoid the increased risks of bleeding, cerebro-vascular accident, cerebral dysfunction and haemodynamic instability associated with cardiopulmonary bypass (Murkin et al, 1999).

Mr Martin was fast-tracked through the immediate recovery period, so he was put on intermittent positive pressure ventilation for three hours. Two hours later, with his pain managed effectively with morphine, he was extubated and transferred to the high-dependency unit in the surgical ward. He had good cardiac function, was haemodynamically stable, his arterial blood gases showed good ventilation, cardiac rhythm was stable and urine output satisfactory.

The concept of fast-tracking may increase the patient’s role in recovery and, by reducing the risk of complications post-surgery, may shorten hospital stay. The next day, Mr Martin’s bed was moved back to its original bay. He was discharged home five days post-surgery. Effective pain relief had enabled Mr Martin to mobilise early, deep breathe and cough, reducing the risk of chest infection. His heart rate was regularly monitored to detect any arrhythmias. His serum electrolytes were also monitored and imbalances that can provoke an arrhythmia corrected early.

After discharge, Mr Martin was referred for rehabilitation. For most patients, phase three cardiac rehabilitation starts around six weeks after MI; however, optimal timing is unclear and may be as early as three weeks (Carrel and Mohacsi, 1998).

The exercise component of the programme was important for improving graft patency. However, because of the sternal wound, Mr Martin was advised not to do weight-bearing arm exercises or swim. Following rehabilitation, Mr Martin felt more confident in his ability to undertake moderate exercise and returned to work.

Further reading
Fisher, S., Walsh, G., Cross, N. (2001)
Nursing management of the cardiac surgical patient. In: Hatchett, R., Thompson, D. (eds). Comprehensive Cardiac Nursing. Edinburgh: Churchill Livingstone.

 

 

Carrel, T., Mohacsi, P. (1998)Optimal timing of rehabilitation after cardiac surgery: the surgeon’s view. European Heart Journal 19: (suppl), 038-041.

Jairath, N. (1999)Coronary Heart Disease and Risk Factor Management: A nursing perspective. Philadelphia, Pa: W.B. Saunders.

Murkin, J., Boyd, W., Ganapthy, S. et al. (1999)Beating heart surgery: why expect less central nervous system morbidity? Annals of Thoracic Surgery 68: 4, 1498-1501.

Riley, J., Blue, L. (2001)Assessing and managing chronic heart failure Professional Nurse 16: 1112-1115.

 

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