REFERENCE CARE PLAN: POST-OP CARDIAC SURGERY (6 WEST INPATIENTS)

Patient PopulationThis care plan is for Teck Acute Care Centre 6 West patients who have undergone heart surgery.

DefinitionsCardiac Output: The amount of blood the heart pumps through the circulatory system in a minute. The amount of blood put out by the left ventricle of the heart in one contraction is called the stroke volume. The stroke volume and the heart rate determine the cardiac output.

Problem/Potential Problem Objectives Anticipatory/Therapeutic Nursing Interventions Evidence-base/Rationale

Potential for Altered Cardiac Output

The patient will maintain adequate perfusion and hemodynamic stability during the post-operative period.

Assess vital signs including HR, RR, BP and temperature q2h for 24 hours on admission.

Transition to q4h vitals once deemed stable by Nurse Practitioner (NP), Most Responsible Physician (MRP) or Designate.

Perform apical heart auscultation for a full minute. Assess pulses, capillary refill, skin temperature and color

with vital signs. Continuous cardiorespiratory monitoring for 24 hours on

admission. NP or physician to reassess and prescribe ongoing monitoring requirements.

Print/record an ECG strip upon admission, at the start of each shift and prn. Preform a 4 step analysis of the rhythm as per the ECG lanyard card and attach the ECG strip to the patient’s Daily flowsheet or nurses notes. Compare findings to patient’s baseline and determine if any changes. Notify NP or physician if changes or dysrhythmia’s are observed.

Continuous oxygen saturation monitoring for 24 hours on admission and then as ordered.

Complete a daily weight prior to first morning feed or at a planned time each day.

Monitor, measure, calculate and document intake and output q12h or as per orders.

Increase frequency of assessment and vital sign monitoring post pacing wire removal as per policy: “Monitoring patients with a temporary external epicardial pacemaker ”

Frequent assessment in conjunction with Continuous Cardiorespiratory monitoring will allow for early detection of hemodynamic changes and promotes early intervention and treatment for altered cardiac output or changes from baseline.

Monitor does not replace clinical assessment

Potential for Respiration will remain easy Assess respiratory rate, effort and breath sounds with This establishes a baseline to track

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REFERENCE CARE PLAN: POST-OP CARDIAC SURGERY (6 WEST INPATIENTS)

Problem/Potential Problem Objectives Anticipatory/Therapeutic Nursing Interventions Evidence-base/Rationale

Respiratory Distress and regular and oxygen saturations will stay within the patients prescribed range.

each set of vitals and prn. Visualize and count respiratory rate for a full minute. Evaluate WOB.

Perform site to source safety check and assessment of Blake Chest Tube drain q1h as per policy. Strips drain Q2h. Empty collection bulb q4h and document output (color & amount) on the Intake and Output section of the Daily flowsheet.

Increase frequency of assessment and vital signs post blake drain removal as per policy: “Blake chest tube maintenance and removal”

Encourage deep breathing and coughing q2h to q4h. Incorporate tools and resources to assist with deep breathing activities including incentive spirometry, bubbles, and pin wheels. Contact Child Life for patient and family support. Teach family how to assist with deep breathing.

Provide supplemental oxygen as needed and ordered per NP or Physician’s orders.

Encourage normal caregiver/baby interactions such as holding/cuddling/rocking that promotes comfort and bonding.

Encourage mobilization and refer to physiotherapist for assistance with ambulation and positioning if needed.

Teach parents to observe for signs and symptoms of respiratory distress/cardiac distress which include:o Change in work of breathingo Colour changes to lips, nailbed, or body(pale,

mottled, cyanosis)o Decrease in appetite or intakeo Increased lethargy(tires easily) or apathy(less

interested in play)

and compare changes in the patient’s status and allows for early recognition of changes. The monitor does not detect changes in the work of breathing.

Monitoring post removal allows for early identification of complications including respiratory distress/failure and pneumothorax

Chylothorax is the accumulation of lymphatic fluid or chyle in the pleural space. The milky appearance associated with chylous drainage is not conclusive for diagnosis. Chylous drainage will be clear or light yellow in fasting children. (3)

Arrhythmias Patient will maintain normal sinus rhythm or stable baseline rhythm.

Ensure the patient is correctly admitted onto the Philips monitoring system by checking settings at the beginning of each shift for any patient with a pacemaker. Ensure the PACEMAKER function/mode is activated on the Philips monitor.

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REFERENCE CARE PLAN: POST-OP CARDIAC SURGERY (6 WEST INPATIENTS)

Problem/Potential Problem Objectives Anticipatory/Therapeutic Nursing Interventions Evidence-base/Rationale

Provide Continuous Cardiorespiratory monitoring as ordered.

Refer to the Non-Invasive hemodynamic monitoring SilP for instructions on monitor use.

Print/record a strip at the beginning of each shift and at any time an arrhythmia is suspected. Inform NP or physician.

Obtain 12-Lead ECG as ordered or when needed. The ECG technician completes 12 lead ECG on Monday - Fri days from 08:00- 16:00. After hours the unit RN, NP or physicians obtain the 12 lead ECG. Ensure patient identifiers are entered (names and MRN) on the machine. See “ECG Procedure and Lead Placement Guide: Pediatrics”

For patients with a temporary pacemaker : Assess patient settings at the beginning of the shift and

compare settings with prescribers order noting mode, rate, output and A-V interval and battery level.

Perform site to source safety check Q1h assessing pacing wire exit site for signs of infection or catheter tension. Ensure the wires are secured to the patient’s skin and connected to the pacer box.

Assess temporary pacemaker settings after each time the rhythm is evaluated by physicians and prn.

Verify that the battery has been changed within the previous 7 days.

Ensure backup temporary pacemaker is available on the unit.

Assess rhythm strip and determine if pacemaker is sensing and capturing appropriately.

Increase frequency of assessment and vital sign monitoring post pacing wire removal as per policy: “Monitoring patients with a temporary external epicardial pacemaker”If changes in rhythm is suspected:

o Assess patient and pulseso Record/print a stripo Perform set of vital signs

“Normal AV node conduction may be affected by tissue trauma related to edema or by direct injury from the suture lines.” (4)

JET is the most frequent arrhythmia during and after congenital cardiac surgery. The ECG is the only available method to diagnose JET, demonstrating inverted P-waves and VA-dissociation. (1)

Refer to “Descriptions of Abnormal Pacemaker Function” on Epops

Confirm that palpable heart rate (mechanical cardiac function) correlates with heart rate (electrical cardiac function).

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REFERENCE CARE PLAN: POST-OP CARDIAC SURGERY (6 WEST INPATIENTS)

Problem/Potential Problem Objectives Anticipatory/Therapeutic Nursing Interventions Evidence-base/Rationale

o Monitor for signs of low cardiac output o Inform NP or physician.

Infection Patient will remain free of signs and symptoms of infection

Assess all dressings at start of shift and with each set of vitals. Note any signs of infection such as purulent drainage from incision site, redness, swelling or pain. Change sternal dressing 48 hours post-operatively then once daily and prn as ordered.

Change Blake Chest tube dressing if saturated (once discussed with NP), otherwise occlusive dressing remains on site until drain removed.

Post –drain removal, the dressing is left on for 48hrs then removed and left open to air.

Follow aseptic wound care technique. Administer prophylactic antibiotics until removal of drains

as ordered. Involve Child Life to engage in age appropriate

distraction techniques for procedure Administer analgesics 30 minutes prior to procedure.

Refer to “Caring for your child’s chest wound” teaching sheet Typically the 1st dressing change coincides with NP removing Blake and Pacer wires.

Prevents or treats infections

Pain Patient’s pain is well managed

Assess and document pain with every vital sign check (q2h to q4h) or as ordered, using an age and developmentally appropriate pain tool. If pain is present, implement pain management interventions and reassess

Administer analgesics as ordered Ensure physical and psychological techniques are used

to supplement pharmacological techniques:1. Physical: Repositioning, deep breathing,

mobilization2. Psychological: distraction (movies, music, toys,

books, video games), education, relaxation3. Refer to child life specialist as appropriate

Altered Nutrition Provide adequate nutrition and caloric intake for patient’s specific needs

Calculate and document accurate ins and outs q12h or more frequently as ordered.

Advance oral diet post operatively as ordered from clear fluids to diet as tolerated.

If breastfeeding, document duration of feed and quality of latching and suck/swallowing coordination. Consider involving lactation consultant. If bottle feeding expressed

Children with CHD may have difficulty with oral motor skills and problems coordinating sucking and swallowing leading to increased risk of aspiration.

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REFERENCE CARE PLAN: POST-OP CARDIAC SURGERY (6 WEST INPATIENTS)

Problem/Potential Problem Objectives Anticipatory/Therapeutic Nursing Interventions Evidence-base/Rationale

breast milk or formula, monitor frequency, volume and tolerance of patient’s feeds noting if the child is settled, irritable, or gagging/vomiting during feed. Assess if the respiratory/cardiovascular status changes with feeds (more tachycardia, tachypnea or diaphoretic) which indicates are they expending extra energy/calories trying to feed.

Refer to Occupational Therapist if patient requires assessment for uncoordinated or impaired feeding ability.

Insert NG tube as ordered to provide enteral feeds as ordered. Some patients may require supplemental or “top up” feeds after a set amount of time orally feeding.

Refer to Cardiac dietician for changes in diet or formula (hyper caloric, additives) Sodium restricted or low fat (chylothorax) diets.

Provide enteral nutrition as ordered and begin teaching with family as needed.

Assess patient’s elimination habits (stooling, voiding). Record stools using the Bristol Stool Chart. Provide bowel protocol and administer medication as needed and ordered.

Perform regular Dental Care. Give medications before brushing teeth.

Breastfeeding is recommended for most babies as it is easier for the baby to suck, swallow, and get more oxygen during feeds.(Heart and Soul).

“Top up” feeds are used when the length of time and energy required to orally feed are greater than the energy derived from the feed.

Standard baby formula is 20 kcal/oz (67 kcal/100mLs). Higher calorie formulas include 24 kcal/oz (80 kcal/100mLs) or 27 kcal/oz (90 kcal/100mLs).

Children with CHD need special attention to their teeth for several reasons: they have poorer oral health than other children leading to more cavities, gum disease and infections. They are at twice the risk to develop unusual conditions such as enamel hypoplasia.

Patient and Family Anxiety and Ineffective Coping

Provide comprehensive orientation for patient and family members to the unit and daily medical routines.

Utilize the information guides on the television in the patient rooms to allow families to understand the resources in the hospital (surgical unit routine, access to food on campus, patient & family resource library).

Encourage use of the whiteboards in the patient room to

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REFERENCE CARE PLAN: POST-OP CARDIAC SURGERY (6 WEST INPATIENTS)

Problem/Potential Problem Objectives Anticipatory/Therapeutic Nursing Interventions Evidence-base/Rationale

communicate with the medical team and ask any questions.

Encourage family participation in daily rounds. Cardiology rounds occur at 07:00 Monday to Friday and at 0800 on weekends. Afternoon rounds typically take place between 15:30 – 16:30.

Promote autonomy by involving family in patient care where appropriate (bathing, feeding, changing, ambulation, playtime, dressing changes, medication administration).

Observe family for coping strategies and offer assistance when needed.

Incorporate specialized support services into care as appropriate including: Child Life Specialists, Spiritual Care, Aboriginal Liason, and School Teacher.

Incorporate Social work to consider: financial help for buying special formulas such as Nutramigen and Monogen, when home oxygen is required, when special authority medications are required or if NG and other feeding supplies may be needed.

Seek referral to psychology as appropriate (ineffective family coping, complex family situations, high risk/high anxiety patient situations)

Promotes family centered care

Collaboration between family and health professionals improves functional outcomes and quality of care

Patient and Family Discharge planning and teaching

To provide comprehensive family centered education and information

Provide, review and assess understanding of discharge teaching resources with the family including:

1. ‘Caring for your Child after Heart Surgery’ (Document #BCCH1445)

2. “Caring for your Child’s Chest Wound” (Document #BCCH1638)

3. Medication education sheets

Provide documentation on ‘Cardiac Surgery Postoperative Teaching’ flowsheet to communicate patient and family teaching between nurses

Bedside nurse to demonstrate sternal dressing change to family. Family to return demonstrate dressing change to

Patient and family centered teaching, alongside the Teach-Back Method have been shown to be effective.

Teaching should be provided throughout the hospital stay and be reinforced by the nurse as needed.

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REFERENCE CARE PLAN: POST-OP CARDIAC SURGERY (6 WEST INPATIENTS)

Problem/Potential Problem Objectives Anticipatory/Therapeutic Nursing Interventions Evidence-base/Rationale

nurse prior to discharge (using their own words to demonstrate understanding)

Provide medication teaching and ensure caregivers have demonstrated the ability to withdraw liquid medication using a syringe. If required, demonstrate crushing tablets and mixing with water/soft food. Reinforce the need to deliver the medications at the appropriate and consistent time.

If child vomits medication: repeat the dose if the child vomits immediately after the medication is given. Wait 10 minutes for the stomach to settle and repeat the dose. If the child vomits more than 20 minutes after dose do not repeat it and continue with the usual schedule. If unsure contact NP, Physician or Pharmacist.

Review preliminary discharge sheet. Ensure family understands when to return for follow-up appointments and who to contact after discharge.

Ensure family has picked up discharge prescriptions. Immunizations : Consult with NP and physicians clinic

to ensure clear plan prior to discharge. For children that require anticoagulation : Ensure

point of care RN/clinic nurse has provided caregiver follow up information.

Medication is part of the child’s lifelong daily routine. Set child up for success by offering choices (what kind of juice afterward) or offering small rewards. Engage Child Life and the Pharmacist to become involved in developing a plan for patients where compliance is a challenge.

Cross-References Blake Chest Tube Maintenance and Removal: http://policyandorders.cw.bc.ca/resource-gallery/Documents/BC%20Children's%20Hospital/CC.09.01.A%20Blake%20Chest%20Tube%20Maintenance%20and%20Removal.pdf

Elsevier Clinical Skills:http://lms.elsevierperformancemanager.com/ContentArea/NursingSkills/GetNursingSkillsDetails/?skillkeyid=14826&skillid=CNP_016

Monitoring Patients with a Temporary External Epicardial Pacemaker: http://policyandorders.cw.bc.ca/resource-gallery/Documents/BC%20Children's%20Hospital/CC.09.05%20Monitoring%20Patients%20with%20a%20Temporary%20External%20Epicardial%20Pacemaker.pdf

Post Heart Transplant Reference Careplan: http://policyandorders.cw.bc.ca/resource-gallery/Documents/BC%20Children's%20Hospital/00.00%203M%20Cardiac%20Heart%20Unit%20Post%20Heart%20Transplant%20Reference%20Care%20Plan.pdf

PICU CARD SURG Post-Operative Day 1 Ward Transfer: http://policyandorders.cw.bc.ca/resource-gallery/Documents/Order%20Sets/PICU%20CARD%20SURG%20Post%20operative%20Day%201%20Ward%20Transfer%20PD%20July%2020,%202016.pdf

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REFERENCE CARE PLAN: POST-OP CARDIAC SURGERY (6 WEST INPATIENTS)

Heart and Soul: Your Guide to Living With Congenital Heart Disease. http://www.bcchildrens.ca/health-info/coping-support/heart-disease

References

1. Cools, E., Missant, C. (2014). Junctional ectopic tachycardia after congenital heart surgery. Acta Anaesthesiol Belg., 65(1), 1-8.

2. Kornburger, C., Gibson, C., Sadowski, S., Maletta, K., & Klingbeil, C. (2013). Using “Teach-Back” to promote a safe transition from hospital to home: An evidence-based Approach to improving the discharge process. Journal of Pediatric Nursing, 28(3), 282-291.

3. Suddaby E, Schiller S. (2004). Management of Chylothorax in children. Pediatric Nursing, 30, 290-5.

4. Skippen, P., Sanatani, S., Gow, R., Froese, N., (2008). Diagnosis of Post-operative Arrhythmias following Cardiac Surgery.

Version HistoryDATE DOCUMENT NUMBER and TITLE ACTION TAKEN05-Dec-2018 C-05-10-60000 Reference Care Plan: Post-Op Cardiac Surgery (6 West Inpatients) Approved at: BCCH Best Practice Committee

DISCLAIMERThis document is intended for use within BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document. This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.

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