Discharge Planning for a Patient after Coronary Artery Bypass Graft Surgery - Lab Report Example

Discharge Planning for a Patient after Coronary Artery Bypass Graft (CABG) Surgery By Candi s Number 2009 FACULTY OF NURSING Coronary heart disease is a major concern for the older adult population in the West and in many other countries around the world. However, it is important to understand that it is possible to treat coronary heart disease and Coronary Artery Bypass Graft (CABG) surgery provides significant relief to patients in terms of bringing about an improvement in their quality of life and a reduction in mortality. Recovery from a shocking experience requires that the patient and their caregivers know what is likely to benefit them the most and how to cope at home with the aftermath of surgery. Discharge planning is about determining what a patient needs for a smooth move from one level of care to the other, as they shift from a hospital surgical ward to recover at home as an outpatient. It is certainly best to prepare a patient for recovery rather than to leave them in the dark to experience new things all by themselves because not knowing can have negative consequences. This write-up presents discharge planning for a patient who has had Coronary Artery Bypass Graft surgery performed on them in a surgical ward and is preparing to shift to their home. Contents Introduction 1 Patient Profile 3 Discharge Planning for the Patient and Criteria for Safe Discharge 6 Conclusion 8 Referral Letter 10 Bibliography / References 12 (This page intentionally left blank) Introduction Coronary Artery Bypass Graft surgery (CABG) is a surgical procedure that is performed to open blocked coronary arteries using grafts from a patient’s own arteries or veins located in the leg, arm or chest (Senagore, 2004, Pp. 346 – 352) and (Fuster, 2009, Chapter 65). The grafted arteries or veins replace blocked coronary arteries to restore blood flow to the heart and to present an improved performance by this vital organ, resulting in relief from chest pain, ischemia and an improvement in patient’s quality of life together with expectations of prolonging a patient’s life. However, CBGR is an invasive procedure carried out under general anaesthesia and the patient recovers under intensive care with assisted breathing administered by a mechanical ventilator. Prior to discharge, the patients usually spend a few days under observation in a non-surgical unit and are counselled and prepared for their discharge. Discharge planning refers to the process that is used to determine what a patient needs for a smooth move from one level of care to the other (Birjandi, 2009, Pp. 1 – 2). It is important to understand that discharge planning is not just about assisting patients to arrange for care after leaving a hospital. Discharge planning is about observing, analysing and deciding about how best to assist a patient to continue with their recovery at home after a physician has determined that the patient’s condition is stable enough for transfer to the next level of care. A patient transferred to their home after a CABG procedure will still need to care for their incision, cope with discomfort and bring about lifestyle changes that help them to benefit most from an expensive and discomforting surgical procedure (Senagore, 2004, Pp. 346 – 352). The patient and their caregivers will have to put in the effort to manage risks and to do well after a CABG. Often, patients perceive heart surgery as a huge personal shock and early and adequate discharge planning that takes into account knowledge of the post discharge experience helps with optimal recovery (Theobald, 2004, Pp. 483 – 485). Clearly, all civilised persons, societies and medical workers want people to live happy and fulfilling lives because all schools of religious and ethical thought dictate that everyone is obliged to make every effort to preserve life and to enrich it until only the Creator decides about a transition (Larue, 1985, Chapter 1) and (ReligionFacts, 2009, “Euthanasia and Religion”). Thus, a discussion of discharge planning for CABG surgery is important for all medical workers, heart patients and those with an interest in giving care to heart patients. Discharge planning for a patient who was cared for in ward five after CABG is below. Patient Profile The patient is a sixty-year-old Caucasian male who is now retired and lives at home with his spouse. He is from middle – class background and used to be actively involved in outdoor activities prior to onset of acute chain pain for which he shifted to be cared in the hospital. The patient is an ex-smoker who kicked the habit some years back and he has had a balloon angioplasty performed on him in 1989. He suffers from hypertension, rheumatoid arthritis and dyslipidemia. The patient had been taking Methtrexatea and Prednisolon for relief of rheumatoid arthritis. His height and weight on admission were 200 cm and 110 kg respectively. He transferred to the Thoracic, Vascular and Cardiac Surgery Ward from Tauranga Hospital on 20/7/2009. Tauranga Hospital had admitted the patient after several episodes of acute chest pain while on a tramping trip and had later referred the case to the surgical ward. The patient suffers from ongoing angina, rising ETT and triple vessel disease for which he had to undergo CABG on 23/7/2009. He was used to exercising and was in a reasonably fit condition for his age despite his ailments. The patient’s case history is below. Case History Demographics: 60-year-old, male, Caucasian Date of Presentation: July 20, 2009 Presenting Complains: Acute chest pain on physical exertion while on a tramping trip, followed by several subsequent episodes of chest pain Illness History: The patient had been in a reasonably good condition until the morning of July 20, 2009 when they experienced an acute onset of chest pain on exertion while on a tramping trip. Despite cessation of physical exertion, several episodes of chest pain presented later and the patient reported to Tauranga Hospital. The patient opined that they were convinced that even moderate exertion would trigger chest pain and seeking medical assistance had become necessary. Past Medical and Surgical History: The patient suffers from rheumatoid arthritis and hypertension. He was an ex-smoker and this means that it is likely that coronary artery disease had progressed gradually despite the patient giving up smoking. The patient has had balloon angioplasty performed on them in 1989, which is now ten years back. Family History: The patient’s father had suffered from heart disease, making it likely that the genetic risk factors are against the patient. Social History: Apart from being an ex-smoker and a moderate drinker, the patient has no history of other addictions. He is married with a spouse five years younger than he is and the couple have two children, a boy and a girl who are now adults and live independently. The patient used to work as a public servant involved with administration until he decided to retire. However, the patient has tried to maintain physical fitness by remaining actively involved with tramping and light aerobic exercise. Findings on Examination: ECG was high on admission to hospital. ST segment takeoff presented itself, but there was no evidence of acute ischemic changes. Coronary angiogram performed after admission when patient returned to hospital with complaints of persistent chest pain presents evidence of diffuse coronary artery disease with severe lesions involving crux of RCA with distal circumflex / terminal OM complex with further evidence of moderate disease of proximal mid LAD and intermediate. Investigations ordered and Results: A second coronary angiogram confirmed the findings of the first coronary angiogram to present lesions in LAD, CX, OM2 and RDA. Nursing Assessment: The patient presented progressing coronary artery disease with evidence of being physically fit enough to benefit from surgery. Medical Assessment by Doctor and Surgeon: Patient will benefit from CABG surgery. Diagnosis: The patient presented progressing coronary artery disease. Disease has gradually progressed over the years to present lesions in LAD, CX, OM2 and RDA that will benefit from CABG to present improvements for patient with decent long-term prospects because of their fitness. Management Plan for Condition: Based on the two coronary angiograms performed on the patient and assessment by the surgeon, a decision to perform CABG proceeded. The patient underwent a CABG surgical procedure on the evening of July 23, 2009. Clinical Course: The patient made a smooth recovery with an uneventful stay in the ICU. An absence of intra and post-operative complications were indicative of a routine recovery. The patient had their chest drains removed on July 25, 2009 and a removal from telemetry and pacing wires occurred on July 28, 2009. He commenced on ciprofloxacin for wound management and later switched to PO flucloxacilling on July 29, 2009 for wound healing. The patient will continue with K supplementation and monitoring. A mixed approach for pharmacotherapy resulted in the patient with a mix of antiplatelet agents, beta-blockers, calcium antagonists, anticoagulants, angiotensin receptor blockers as discharge medications. Discharge Planning for the Patient and Criteria for Safe Discharge Discharge planning for patients who have undergone CABG includes assessing a patient to determine if it is proper to shift the patient to home care, assisting patients and primary home caregivers to anticipate likely problems after discharge and to prepare the patient for the difficult few months after their return home (Theobald, 2001, Pp. 11 – 12). The discharge process takes into account if a patient is conscious, decides about their cardiovascular and respiratory stability and determines if condition of the wound site is satisfactory together with deciding if prevalence of nausea and vomiting is minimal and controlled. In addition, medical workers must consider if patient’s recovery at home is likely to be satisfactory in the light of all available evidence. Thus, the discharge process and discharge planning must embrace the physical, psychological and social aspects of patient care to try to achieve the optimal. Medical literature does not present an optimum day for discharge after cardiac surgery and it is the condition of the patient determines this, but it is important to remember that prolonged stay in a hospital adds to the cost (Inwood, 2002, Chapter 11). Patients and the primary caregiver confront a myriad of stresses created by the acute nature of CABG and the underlying etiology of coronary artery disease. Immediately after CABG surgery, a patient must confront pain, edema, wound drainage, fever and fatigue, sleep problems, incision discomfort and shortness of breath together with loss of taste acuity and concerns related to amount and odour of perspiration. For the first two weeks after CABG, patients tire easily and sleep most of the time. The effects of aging and complications arising out of the impact of a patient being afflicted with other conditions in addition to coronary artery disease slow the recovery process. Thus, older patients with other complications are likely to stay longer in a hospital compared to younger patients. In addition to the physiological problems, psychological reactions that manifest themselves in patients who have undergone CABG include heightened anxiety, delirium after surgery, depression and intellectual dysfunction. Feelings of helplessness, fear of impairment and a fear of dying can interfere with a patient’s recovery after CABG. Thus, it is important that hope, positive attitude and efforts to present an uplifting mood prevail. A mix of group and individual discussions that provide information and counselling about how best to cope, what to expect and how to deal with future are important to prepare patients and caregivers. It is important to emphasise on diet, hygiene and wound care, exercise, pain management, relaxation with light classical music and evident individual concerns in discussions prior to discharge. Clearly, if a patient is unconscious and lacks cardiovascular and respiratory stability, they can present an acute emergency at home and are unlikely to receive adequate response urgently from the primary caregiver. In addition, it is best not to expose patients who are recovering to rigors of shifting back to the hospital. A clean wound that is healing is acceptable for discharge but indications of wound complications can become acute without evidence of normal healing. The primary caregiver must be able to cope with the added stress and burden. If a primary caregiver is absent or lacks the capacity for care, then the patient will have to be further stabilised prior to shifting to home where day care or community health workers can assist them further. Conclusion Discharge planning is important because this process assists the patients to benefit from the experience and knowledge of medical workers about what they are likely to encounter and how best to approach their recovery. It is certainly best to prepare a patient for recovery rather than to leave them in the dark to experience new things all by themselves because learning new things as they occur is difficult and may impair recovery. Referral Letter (This page intentionally left blank) Bibliography/ References 1. Birjandi, Ali and Bragg, Lisa M. (2009). Discharge Planning Handbook for Healthcare: Top 10 Secrets for Unlocking a Revenue Pipeline. CRC Press. 2. Fuster, Valentine et al (Editors). (2009). Hursts The Heart, 12e. McGraw Hill. 3. Goudie, Ann Beth. (1997). The Transition from Hospital to Home following Coronary Artery Bypass Graft Surgery. University of Alberta. Retrieved: August 23, 2009, from: http://www.scirus.com/srsapp/sciruslink?src=ndl&url=http%3A%2F%2Fwww.collectionscanada.ca%2Fobj%2Fs4%2Ff2%2Fdsk2%2Fftp04%2Fmq22742.pdf 4. Grech, Ever D (Editor). (2004). ABC of Interventional Cardiology. BMJ. 5. Inwood, Helen L. (2002). Adult Cardiac Surgery Nursing Care and Management. Whurr Publishers. 6. Kaul, Padmaja Ravikanti. (2000). Predictors of Adverse Events within One-Year Following Percutaneous Coronary Intervention. University of Alberta. Retrieved: August 23, 2009, from: http://www.scirus.com/srsapp/sciruslink?src=ndl&url=http%3A%2F%2Fwww.collectionscanada.ca%2Fobj%2Fs4%2Ff2%2Fdsk1%2Ftape4%2FPQDD_0011%2FNQ59607.pdf 7. Larue, Gerald A. (1985). Euthanasia and Religion: A Survey of the Attitudes of World Religions to the Right-To-Die. Grove Publishers. 8. ReligionFacts. (2009). Euthanasia and Religion. ReligionFacts. Retrieved: August 23, 2009, from: http://www.religionfacts.com/euthanasia/index.htm 9. Senagore, Anthony J. (Executive Advisor). (2004). The Gale Encyclopedia of Surgery. Thomson Gale Publishing. 10. Short, Elison Edna. (2003). Holistic Aspects of Rehabilitation Post-Cardiac Surgery in the Bonny Method of Guided Imagery and Music. University of Technology, Sydney. Retrieved: August 23, 2009, from: http://epress.lib.uts.edu.au/dspace/handle/2100/238 11. Singh, Vibhuti N et al. (2008). Cardiac Rehabilitation. eMedicine. Retrieved: August 23, 2009, from: http://emedicine.medscape.com/article/319683-overview 12. Theobald, Karen and McMurray, Anne. (2004). Coronary artery bypass graft surgery: discharge planning for successful recovery. Journal of Advanced Nursing 47(5):483-491. Retrieved: August 23, 2009, from: http://eprints.qut.edu.au/1577/1/1577.pdf 13. Theobald, Karen. (2001). Influences on Post-Discharge Recovery Following Coronary Artery Bypass Graft Surgery. Griffith University. Retrieved: August 23, 2009, from: http://www4.gu.edu.au:8080/adt-root/public/adt-QGU20050901.113004/ 14. Veroni, Margherita. (2006). The Use of Pharmacotherapies in the Secondary Prevention of Heart Disease. The University of Western Australia. Retrieved: August 23, 2009, from: http://theses.library.uwa.edu.au/adt-WU2006.0029/ Read More