Pre Surgical Education and Assessment

http://www.webhealthcentre.com/Healthcorners/cardiac_pre_surgery.aspx

Cardiac Surgery: a team effort 

Learning the following for early recovery

• The importance of clearing the lungs in the post op period
• Deep breathing technique
• Coughing technique
• Range of Motion Exercises

Getting ready for the surgery

Informed Consent

It is usual to admit patients 2 to 3 days before the planned date of surgery. This allows time for pre-operative testing. Cardiologists and surgeons will see you.

The medical team that works with you will consist of:

• Cardiologist: A Cardiologist specialises in the diseases of the heart. He will diagnose your heart's condition using non-invasive or invasive methods and charts out the management plans.
  
• Cardiac surgeon: The Cardiac surgeon will determine the most appropriate surgical procedure to help you. He will perform your surgery and supervise the post-surgical care.
  
• Cardiac anaesthetist: The Cardiac Anaesthetist is responsible for safely anaesthetising you for surgery and also for your immediate post surgical care. Before surgery he will ask you questions about your medical and surgical history and whether you are allergic to any medications that might be used.
  
• Cardiac rehabilitationist: Cardiac Rehabilitationist is a doctor who specialises in rehabilitation medicine. He coordinates the efforts of the cardiac rehabilitation team, counsels you and your family. He designs the exercise program to match your ability and limits set by your physician.
  He can explain how you can save energy at home, at work and in recreational activities.
  
• Cardiac nurse: Cardiac Nurses are specially trained to provide personalised care to heart patients. They will talk with you and your family about your surgery and progress pattern.
  
• Physical therapist: The Physical Therapist, trained in cardiac rehabilitation, will help you carry out the exercises prescribed, thereby preventing deconditioning effects.
  
• Clinical psychologist / social welfare officer: The Clinical Psychologist evaluates your personality type, emotional, behavioural aspects for counselling and advises you on stress management with life style modification.The Social Worker evaluates the social and financial needs of patients and your family. The social worker will be available to talk to you about any problem.
  
• Dietician: The Dietician will evaluate your daily nutritional needs and will plan meals according to your doctor's recommendations. If your doctor recommends a special diet at home, the dietician will instruct you about it.

Pre-operative Education

Clearing your lungs of mucus

Breathing and Coughing Exercises are essential after surgery. These help clear the mucus which collects in the lungs during any major surgery. If it stays in the lungs, it can cause health problems. You must cough up as much as you can. Deep breathing opens up the tiny air sacs in the lungs. Coughing helps to bring up mucus.

Coughing techniques and deep breathing exercises are of considerable importance to patients who are obese and those who are smokers. These exercises may give you a little discomfort and may be bit painful but they will help towards a quick recovery. They won't harm your incision.

You may do these exercises in a bed or while sitting on the chair. If in bed, raise your head off the bed until you are in a sitting position. Bring you knees up to relax your stomach muscles. Hold a pillow or folded blanket firmly against your incision. Stay in this position for the exercises. If in a chair, sit with your back supported and feet on the floor. Hold a pillow or blanket firmly against your incision.

1. Inhale slowly through your nose for the count of 2. Your rib cage and abdomen should expand. Relax your upper chest and shoulders.
   
2. Exhale slowly through the mouth for the count of 4.
   
3. After doing 1 & 2 several times, breathe in slowly through your nose, open your mouth, stick out your tongue and cough hard 3 times as you breathe out. Try to pull in your abdominal muscles as you cough, repeat step 3 several times.
   
4. Initially a therapist will help you with these exercises. He/she may 'clap' your back to help loosen the mucus. It is also helpful to take sips of water.

Sometimes an incentive spirometer is used. This device encourages you to breathe deeply. A deep breath held for a few seconds prevents pulmonary complications more effectively than multiple deep breaths that are immediately exhaled.

Deep Breathing Technique

When you breathe, are your upper chest muscles doing all the work? If so, learn to use your diaphragm. Your chest muscles weren't designed to do all the work involved in breathing. Your can breathe more efficiently and with less effort if you use your diaphragm and other abdominal muscles. This technique will increase your breathing capacity, improve ventilation to the lung bases, and decrease your energy expenditure.

Regular practice is required to train your diaphragm to carry the workload of breathing. At first, you may tire easily. But as you progress you will find diaphragmatic breathing's less exhausting than breathing with your chest muscles. Soon, you will use this technique automatically.

Before beginning the breathing exercise, make sure your nasal passages are clear. If congested, blow your nose, and use any medicated aerosol treatment your doctor may have prescribed.

Lie flat on your back, and flex your knees and hips slightly. Now, place one hand over your chest and the other over your upper abdomen. Relax.

With your mouth closed, inhale deeply through your nose. As you do, make your abdomen rise as far as it will go. Try not to actively expand your chest. If the hand on your abdomen rises as you inhale, you're doing it correctly. Remember, this breathing exercise may take time to master, so don't become discouraged.

Purse your lips, as if you're going to whistle. Exhale slowly. While you're exhaling, you may press your lower hand upward to force air from your lungs. Continue this breathing exercise for 10 to 30 minutes, depending on your strength. Stop when you get tired. Repeat the entire exercise atleast three to four times daily. Remember to exhale through pursed lips, taking twice as long as you do to inhale.

As soon as you've mastered diaphragmatic breathing while lying flat, try the exercises while standing, and finally while walking. Make it a habit.

Coughing Technique

Effective coughing usually helps you to dislodge pulmonary secretions,

1. First, be seated in a chair, or on the edge of your bed.
2. Support your feet with a stool if they don't reach the floor.
3. Then, hunch your body slightly forward, and take several slow, deep breaths.
4. Then, bend your head forward and cough two to three times in rapid succession.
5. Breathe deeply again, and repeat the entire exercise several times.
6. Splint your incision before you cough. Place one hand above and one below you incision. Splinting is important and remember to do it.

Range of motion (ROM) exercise

These exercises are for your joints. They take them through their full extent of movement. These exercises also maintain joint activity. Besides they stimulate blood circulation and promote muscle tone. The three basic types of ROM programmes are:

1. Passive: Maintains joint activity and motion while you are recovering from the immediate anaesthetic effect. These exercises are performed for you by a physiotherapist.
2. Active assistive: Helps to strengthen and maintain joint activity and motion. You will be able to perform these exercises with minimal assistance from the physiotherapist.
3. Active: Helps strengthen the weakened joints and can be performed by you.

Make these exercises as a part of your daily routine. Repeat each exercise five times

Getting Ready for Surgery

Here are some things to expect.

1. Cleaning the skin: During your evening shower, you will be asked to scrub the places on your leg and chest where incisions will be made with antiseptic surgical soap. This helps reduce the risk of infection. Don't put powder or lotion in these areas.
2. Shaving the skin: Much of your body hair will be shaved off to reduce the risk of infection.
   
3. Diet: your stomach must be empty before surgery. You should not eat or drink anything on your own after midnight. However, your nurse may give you medication with few sips of water. If your mouth gets too dry you can rinse it with water but do not swallow it.
   The nurse in charge will instruct you clearly about the diet you should have on the day before surgery and the time after which you should not eat or drink anything.
4. Bowel movement: Sometimes you may be given an enema or suppository to help you have bowel movements before surgery. If necessary, it will be given the evening before the surgery

Informed consent:

Before any surgical procedure, you will be asked to sign one or more consent forms. This gives the hospital and your doctor permission to treat you. If you are not able to sign, then a member of your family or representative must sign on your behalf. If you have any doubts clarify them before you sign the consent form.

Source: The above material was prepared with the help of the Cardiac Rehabilitation unit at the Institute of Cardio Vascular Diseases, Chennai.