The history includes information about the patient’s health status as well as the response to the disease and the recommended intervention or interventions. Patients with cardiac disease may display such symptoms as ischemic chest pain (angina pectoris), fatigue, dyspnea, and syncope. Depending on their severity, these subjective symptoms affect the patient’s functional status and ability to engage in activities of daily living; the New York Heart Association’s Functional Classification System (Box 25-1) is often used to assess functional ability. Updates to the classification system also include objective measurements such as x-rays and echocardiograms (American Heart Association [AHA], 2012 a,b).

Atypical ischemic chest pain is more likely in women than in men, and angina may arise from vasospastic angina, mitral valve prolapse, or psychologic factors. CAD is unusual in premenopausal women; after menses ends, however, the risk is similar to that of men (AHA, 2013; Caboral, 2013; Mosca et al, 2011; Roger et al, 2012; Wenger, 2012). Controversy exists regarding menopausal hormone therapy. Estrogen hormone replacement therapy is not recommended in postmenopausal women, according to the Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2011 Update (Mosca et al, 2011) (Evidence for Practice). Greater emphasis is being placed on effectiveness of interventions as well as on the evidence supporting those interventions; effective control of blood pressure, diabetes management, and maintenance of optimal lipid levels are significant risk reduction interventions for women (Caboral, 2013).

Women undergoing coronary artery bypass graft (CABG) also have some unique challenges and experiences. According to Banner and colleagues (2011), some women may minimize any public display of illness in an attempt to preserve the appearance of normalcy; they even may hesitate to tell significant others about impending surgery until the day before admission. Postoperatively they may wish to return home early in order to resume regular activities. Once home, some women were unprepared for the limitations that they faced, both physical and social; the authors recommend focused advice, support, and education (Banner et al, 2011).

A cardiovascular disease risk factor profile (Box 25-2) is helpful to plan care for hospitalization and discharge by focusing on areas that might require further patient education. For example, diabetes is a risk factor because it affects the vascular system, may retard healing, and may predispose the patient to infection. Of special concern is the epidemic growth of type 2 diabetes in particular and the role of hyperglycemia in general. Although type 2 diabetes formerly was considered an adult-onset disease, children are increasingly vulnerable because of a greater incidence of increased body weight, sedentary lifestyle, and accelerated insulin resistance (Roger et al, 2012). Altered glucose metabolism (absent diagnosed diabetes mellitus) has shown a significant correlation to atherosclerosis; control of hyperglycemia during coronary bypass surgery is an important strategy to reduce the risk of adverse clinical outcomes (Hillis et al, 2011; Nussmeier et al, 2009).

In addition to elevated lipid or cholesterol levels, inflammation increasingly has been implicated in the development of CAD. In particular, elevated homocysteine levels (which increase platelet aggregation) and high C-reactive protein (CRP) levels have been implicated (CRP is a biologic marker for inflammation and is associated with increased risk for CAD) (Horak et al, 2011). Additional recognized risk factors include metabolic syndrome (central obesity, hypertension, insulin resistance, and dyslipidemia) and obesity (Hillis et al, 2011; Roger et al, 2012). Hypertension and obesity increase the workload of the heart; obesity may also increase the risk for postoperative infection because adipose tissue vascularizes poorly. Additionally, a growing percentage of the population is aging. Age, in and of itself, rarely contraindicates intervention, but comorbidities often associated with older individuals constitute additional risk factors and areas—for example, cognitive impairment, depression, and decision-making capacity—that may require investigation (Chow et al, 2012).

Among the newer biomarkers denoting cardiovascular diseases are the natriuretic peptides—cardiac hormones synthesized and secreted by the atrium (atrial natriuretic peptide [ANP]) and the ventricle (B-type natriuretic peptide [BNP]). Discovered in 1981, natriuretic peptides have a regulatory effect that causes myocardial relaxation in response to acute increases in ventricular volume. Measurement of circulating peptides is increasingly used to identify heart failure and sudden cardiac death. Another biomarker under intensive study as a risk factor is lipoprotein(a) (Lp[a]), which has been identified from genetic studies as a causal link to MI; niacin has been shown to reduce the level of Lp(a) in some individuals (Hall, 2010).

Genetic risk factors for CAD and other cardiac disorders have been identified and are undergoing extensive study (Judge, 2012). Genetic studies have created a burgeoning body of knowledge about genetic mutations associated with risk factors such as CRP and possible pathways linking inflammatory processes with CAD (Kim et al, 2011; Roberts and Stewart, 2012a). Genetic risk variants mediate their risk in multiple ways; researchers have discovered that there are more unknown mechanisms than known mechanisms such as those associated with hypertension or lipids (Roberts and Stewart, 2012b). Soon an integral component of the preoperative assessment likely will include a genetic profile.

The risk for complications and major adverse cardiac events (MACEs) after cardiac surgery also appears to vary somewhat depending on gender (Hillis et al 2011; Newby and Douglas, 2012; Wenger, 2012). Investigations of risk factors in men and women for sternal wound infection have identified three significant risk factors that occur at significantly different rates in men and women: smoking, use of a single IMA, and age more than 70 years. Smoking and the use of a single IMA for bypass grafting are more common risk factors in men compared with women; women tend to be older than men at the time of surgery (Newby and Douglas, 2012). Fewer MACEs arose in women undergoing coronary bypass surgery without the use of cardiopulmonary bypass (CPB)—“off-pump” procedures—compared with surgery with CPB; however, malignant ventricular dysrhythmias (e.g., ventricular tachycardia), a calcified aorta, and preoperative renal failure are poor prognostic signs in women (Newby and Douglas, 2012). These findings should be incorporated into patient and family teaching plans with recommendations for lifestyle changes as indicated.

In addition to health status and risk factors, the perioperative nurse reviews patient medication history with particular attention to vasoactive drugs, anticoagulants, and other medications that can affect surgery. Nurses should note that patients taking aspirin and other antiplatelet drugs (such as 2b/IIIa inhibitors) may require intraoperative replacement of platelets. Lipid-lowering drugs (statins) have shown cardiovascular benefits, but in high doses (i.e., 80 mg, compared to moderate doses of 40 mg), they have been associated with new onset diabetes mellitus (Preiss et al, 2011). Patients taking herbal medicines may be at risk for increased bleeding, hypoglycemia, or other complications, depending on the specific side effects of some herbal drugs (see Chapter 30).

Patient knowledge and understanding of cardiovascular disease and related risk factors and their effect on functional, physiologic, and psychologic status should also be part of the perioperative nursing assessment. The patient’s personal strengths, external resources, and coping strategies are important subjects to consider. The perioperative nurse also notes any cultural, ethnic, spiritual, or religious beliefs that appear relevant to perioperative patient care.

Physical assessment provides the perioperative nurse with baseline information about potential problems that might require intervention. Normal, age-specific changes in very young and elderly populations must be differentiated from pathologic conditions. Chapters 26 and 27 provide extensive age-related considerations.

In addition to age-specific changes, a growing number of adults with acquired heart disease underwent surgery in childhood to repair congenital cardiac lesions (Webb et al, 2012). For example, patients with a previous Blalock-Taussig shunt for tetralogy of Fallot (see Chapter 26) may have altered pulmonary and subclavian artery anatomy. Likewise, patients with a mechanical closure device inserted for an atrial septal defect may be at risk for endocardial injury if the heart is retracted or otherwise manipulated too forcefully. The nurse must be aware that anatomic anomalies associated with the original congenital defect, or its subsequent repair, may mandate alteration of the current surgical plan. Consultation with the surgeon can alert the cardiac team to anticipate different anatomy (and surgical landmarks), special supplies and prosthetic materials, and potential complications.

Before beginning a review of systems, it is helpful to assess the patient’s functional capacity. How are activities of daily living accomplished? What are the barriers that make independent living difficult? How are activities performed when there are disabilities? What support systems are available? What educational resources are available? These and other questions will alert the clinician to the need for referrals and other resources to help the patient achieve optimal outcomes.

A systems review often starts with the skin. The appearance of the skin offers clues to cardiovascular status. Dryness, coolness, diaphoresis, paleness, edema, poor capillary refill, bruising, and petechiae may reflect impaired cardiovascular function. Visual problems and headaches may relate to inadequate cardiac output, atherosclerotic disease, peripheral vascular disease, aortic valve stenosis, or medications such as digitalis. The presence of chronic or local infection must be identified; if untreated, these are potential sources of postoperative infection. Nutritional status assessment (including metabolic syndrome) helps to determine increased risk for infection, skin breakdown, impaired wound healing, and other complications.

The patient’s level of consciousness, memory, comprehension, and emotional status require assessment. Confusion, restlessness, slurred speech, numbness, and paralysis may signal impaired per­fusion. The perioperative nurse should note their presence pre­operatively and communicate this to nurses receiving the patient postoperatively.

During respiratory assessment the perioperative nurse should note the use of accessory muscles or nostril flaring and should auscultate breath sounds. Adventitious sounds such as crackles and wheezes may point to pulmonary edema. Orthopnea, shortness of breath, or dyspnea may require elevation of the head of the stretcher and assistance during transfer onto the OR bed. If the patient is receiving oxygen, the flow rate and method of administration should be observed.

Alleviating pain is a prime consideration in the care of the cardiovascular patient because pain is a myocardial stressor. A patient with angina may arrive in the OR after nitroglycerin tablets have been administered or transdermal patches applied. Cold also increases the workload of the heart because the shivering that accompanies chilling elevates the metabolic rate; the patient should be kept warm.

Heart sounds, murmurs, and friction rubs provide clues to congenital, ischemic, valvular heart disease, or pericarditis. The patient may experience palpitations. Apical, radial, and femoral pulses also reflect cardiac function, and their rate, rhythm, and quality should be determined. The presence of cyanosis or peripheral edema should be noted.

Blood pressure is an important assessment consideration. The hypertensive patient may have left ventricular hypertrophy, and the hypotensive patient may display changes in neurologic, gastrointestinal, and renal function. Blood pressures should be checked bilaterally. Unequal pressures in the arms may be a contraindication for the use of the IMA as a bypass graft on the side of the lower blood pressure, where perfusion may not be optimal. Radial and ulnar artery pulses should be checked bilaterally when the radial artery is to be used as a bypass graft. Patients with dissections or aneurysms may have unequal carotid, femoral, brachial, or radial artery blood pressures when the lesion occludes one or more of these vascular branches.

Cardiac function affects all the body’s organ systems; therefore, assessment of the patient should be comprehensive whenever possible. A thorough assessment also alerts the physician and perioperative nurse to the need for special diagnostic tests and laboratory procedures.

Most patients referred for surgery have had clinical evaluations, including invasive and noninvasive studies (Box 25-3). After the history and physical assessment, a resting electrocardiogram (ECG) follows. An exercise ECG (stress test) is often undertaken because ST-segment changes indicating myocardial ischemia may be apparent only during or after exercise. In patients with intractable dysrhythmias, electrophysiology (EP) studies may help locate irritable atrial or ventricular foci that can be surgically ablated, excised, or controlled with pharmacologic therapy. EP studies also may determine the need for internal defibrillators or antitachycardia devices. Bradycardia may indicate the need for pacemaker insertion.

Chest radiography provides information about the size of the cardiac chambers, thoracic aorta, and pulmonary vasculature as well as the presence of calcium in valves, pericardium, coronary arteries, and aorta (Figure 25-8). Lateral chest radiographs of patients with prior sternal surgery show the chest wires and extent of pericardial adhesions. Magnetic resonance imaging (MRI) enables assessment of myocardial viability and also can image vascular structures with MRI angiograms that provide great clarity (Figure 25-9, A). In patients with suspected aortic or other vascular abnormalities, a computed tomography (CT) scan of the chest with intravenous injection of a contrast medium creates x-ray serial “slices” of the body area under study (see Figure 25-9, B). CT angiography is especially useful to image the aorta and the great vessels. CT images of the coronary arteries are used increasingly to identify areas of coronary calcification (shown in Figure 25-9, B), a recognized CV risk factor. One study demonstrated the value of coronary artery calcium scoring to identify patients who may be asymptomatic for CAD, but are at risk for increased mortality (Tota-Maharaj et al, 2012).

CT scans may be contraindicated in very unstable patients because their position in the tubelike scanner makes patient access difficult. Less frequently performed is arteriography with radiographic contrast dye to determine the size and location of the lesion and the site of the intimal tear in aortic dissections (Figure 25-10); digital subtraction angiography (DSA) provides clear images and requires less contrast material.

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