Cardiomyopathy VII: Pre and Post Operative Nursing Management

Patients with hypertrophic cardiomyopathy (HCM) and left ventricular outflow tract (LVOT) obstruction who remain symptomatic despite optimal medical therapy may undergo a septal myectomy (Morrow procedure). This procedure involves excising a portion of the hypertrophied septum below the aortic valve using a heart-lung machine to improve blood flow through the LVOT. Effective preoperative and postoperative nursing management ensures successful patient outcomes, minimizes complications, and facilitates recovery.

Preoperative Nursing Care

Documentation and Health Assessment

• Thoroughly document the patient's history, including major illnesses, previous surgeries, medications, and use of illicit substances, over-the-counter drugs, herbal supplements, alcohol, and tobacco.
• Ensure the preoperative history and health assessment are well-documented to provide a basis for postoperative comparison.
• Evaluate the cardiovascular system by reviewing chest pain, palpitations, dyspnea, intermittent claudication, and peripheral edema.
• Pay special attention to blood glucose control in diabetic patients due to the higher incidence of postoperative complications with poor glycemic control.

Preoperative Testing and Assessment

• Conduct preoperative tests such as chest X-rays, ECGs, coagulation studies, blood typing, and cross-matching.
• Assess for conditions that could complicate the postoperative course, such as diabetes, hypertension, and lung disease.

Patient and Family Support

• Allow patients and families to express their concerns regarding pain, fear of the unknown, disability or death, and changes in body image.

Education and Instructions

• Provide specific instructions to patients and families on managing medications, including the use or cessation of anticoagulants, antihypertensive agents, diabetes medications, preoperative sedation, surgical anesthesia, and postoperative pain management.
• Inform about hospitalization and surgery, including the equipment, tubes, and lines, and the purposes of the postoperative use.
• Answer questions about postoperative care and procedures.
• Practice deep breathing, coughing, using an incentive spirometer, and foot exercises with the patient.

Postoperative Nursing Management

Initial Postoperative Care

• Focus on achieving or maintaining hemodynamic stability and recovering from general anesthesia, typically in the PACU or ICU.
• Monitor cardiovascular status by obtaining serial readings of hemodynamic parameters such as arterial pressure, central venous pressure (CVP), Pulmonary artery pressures, pulmonary artery wedge pressure, blood pressure, and cardiac rhythm and rate.

Cardiovascular Monitoring

• Assess arterial blood pressure every 15 minutes until stable. Then, the patient will be monitored every 1 to 4 hours for the first 24 hours and every 8 to 12 hours until hospital discharge.
• Auscultate heart sounds and rhythm and assess peripheral pulses.
• Monitor hemodynamic parameters to evaluate cardiac output, volume status, and vascular tone. Assess the requirement for administering blood products or IV fluids.

Vigilance for Complications

• Be vigilant for manifestations of cardiac tamponade, including rising CVP, hypotension and PAWP, pulsus paradoxus, jugular vein distention, and decreasing urinary output.
• Check for diminished blood in the chest drainage collection system, also observe for cardiac failure signs,
• Administer diuretics or IV inotropic agents, as per order.

Respiratory Support

• Auscultate breath sounds and sedate the patient as prescribed. Maintain mechanical ventilation and monitor ABGs, tidal volume, peak inspiratory pressure, and extubation parameters.
• Suction tracheobronchial secretions using an aseptic technique assist in weaning and the removal of endotracheal tubes.

Fluid and Electrolyte Management

• Monitor fluid and electrolyte balance and assess blood pressure, hemodynamic parameters, weight, electrolytes, hematocrit, jugular venous pressure, breath sounds, urinary output, and nasogastric tube drainage.
• Be alert to changes in serum electrolyte levels, particularly hypokalemia, which can cause arrhythmias like premature ventricular contractions and ventricular tachycardia.

Chest Drainage

• Measure postoperative chest drainage.
• Ensure the patency and integrity of the drainage system, as cessation may indicate a kinked or blocked chest tube.