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Carole Gassert, PhD, FACMI, FAAN has been a nursing leader in cardiac surgery and informatics. For many years she served as Clinical Nurse Specialist in Cardiovascular Surgery at the University of Virginia Hospital and Crawford Long Hospital of Emory University. She has taught cardiac nursing at the University of Virginia and Georgia State University. She developed the first nursing informatics program in the world while at the University of Maryland. She served as a nurse consultant in informatics for the Health and Human Services. She directed the informatics program and was Associate Dean for Information and Technology at the University of Utah College of Nursing. Besides this book and the patient book Moving Right Along After Heart Surgery, Carole has contributed numerous articles and book chapters to health care literature. She continues to help patients get ready for heart surgery.
Susan Burrows, MN, RN served for many years as Clinical Coordinator in Thoracic Surgery and Clinical Nurse Specialist in Cardiovascular Surgery at Emory. Besides this book, she coauthored with Carole Gassert, Moving Right Along After Heart Surgery. Susan developed numerous booklets and audiovisual programs for patient education and was a speaker at many cardiovascular conferences. For many years Susan served as an advocate for patients experiencing heart surgery. Even though we have lost Susan, her devotion to caring for others and her love of life will live on!
This book can help you get ready for heart surgery.* You will not only learn about the surgery itself, but you will also find out how to get your mind and body ready for it.
Share Going For Heart Surgery with your family. It will answer many of your questions and help you think of others to ask your doctor or nurse. Do not feel foolish for asking questions or saying what you are feeling. The more you know about what to expect, the easier your recovery will be.
* This book can be used for coronary bypass surgery, heart valve surgery, surgery for congenital defects or surgery for aneurysm of the heart muscle.
This
book should not replace the advice or treatment your doctor or nurse gives you. It is to add to what you are already learning about your heart surgery.
Is there anyone who goes to surgery without a worry? We can’t think of anyone. Having fears and doubts is common. It’s OK for you to have these feelings. Feel free to talk about your feelings too. Don’t bottle them up inside.
It helps to share your feelings with your loved ones. Even if talking about the surgery makes you a little anxious, it will help you get ready for it. Sharing with your family and friends can bring you even closer to one another. And your loved ones will remind you of good times and all the good times you have to look forward to.
You may also want to read what others have written about heart surgery or talk with others who have had it. Just remember that each person’s recovery from surgery is different.
Yes, you can get through it!
One part of getting ready for heart surgery is knowing about the surgery itself. These next pages will give you an idea of what it is like.
Coronary artery bypass graft surgery and valve surgery are the two most common types of heart surgery. Other heart surgeries repair aneurysms (bulging of the heart muscle) and congenital heart defects (defects you are born with). The heart-lung machine has been used commonly to pump blood for the heart and add oxygen for the lungs while surgery is being done. It continues to be used in many heart surgeries. Special tools now allow some heart surgery to be done without the heart-lung machine. These tools make part of the heart quieter while surgery is done on that area. It is called off-pump surgery. Other tools called scopes allow some heart surgery to be done with small chest incisions. Your doctors will decide which type of surgery is best for you.
The heart muscle gets its blood and oxygen through the coronary arteries which surround it. When these arteries are blocked, the heart does not get what it needs. The result can be angina* or a heart attack.
Ask your doctor or nurse to mark where your blockages are.
left coronary artery and its branches
right coronary artery and its branches
right main
AV node branch
acute marginal
posterior descending
left main circumflex
obtuse marginal
ramus
septal perforator
diagonals
anterior descending
* Some signs of angina are: pressure, tightness, squeezing or aching (burning or cramping pains) in the chest, arms, neck or jaw or shortness of breath.
Women more often feel very tired, short of breath, nausea and dizziness.
A coronary artery bypass graft is done to improve blood flow in blocked arteries. During surgery, one or more bypasses may be done with part of a vein from your leg (saphenous vein) or with an artery from your chest (internal mammary artery) or your forearm (radial artery). After the surgery is done, blood flows through the bypass graft and takes blood and oxygen to the heart muscle. Your body can still function properly without the arteries or veins that are used for your bypass.
vein bypass from leg or radial artery from arm
artery bypass from chest
Your coronary artery bypass surgery can be done in different ways. Your surgeon may use either of these to do your coronary artery surgery:
the heart-lung machine (traditional coronary artery bypass)
special tools to quiet part of the heart where the bypass is done (off-pump coronary artery bypass)
small lighted scopes with a surgical system (endoscopic coronary artery bypass)
The type of surgery you will have depends on where your blockages are located, how many blockages you have and which surgery your doctors think is best for your coronary artery blockages.
There are four valves in your heart which act like one-way doors. They let blood in and out of the heart’s chambers each time it beats. Heart valve surgery replaces or repairs damaged or scarred heart valves.
Normal valves let blood move smoothly through the heart.
These valves can be damaged or scarred by birth defects, rheumatic fever, infection or a heart attack. The aortic and mitral valves are the ones most often repaired or replaced. When heart valves do not open or close as they should, the heart has to work harder to get blood through the body. This can weaken the heart and cause pain, shortness of breath, dizziness or other signs. When medicines can’t correct these problems, heart valve surgery may be needed.
Normal valves open and close all the way.
Damaged valves do not open or close fully.
Ask your doctor or nurse to circle your damaged heart valve.
If the valve must be replaced, your doctor will talk with you about different heart valves that can be used. They will be either a mechanical or a tissue valve. The tissue valve may come from an animal or a human. Here are just a few of the valves that can be used. Yours may be a little different from the ones shown here.
You may also have heart surgery for an atrial septal defect or aneurysm of the heart muscle.
Sometimes the wall that divides the heart’s upper chambers does not close all the way. This leaves a hole that lets blood flow between these chambers. The hole is either sewn together or patched during surgery.
atrial septal defect
After a heart attack, part of the heart muscle may be weakened. If this happens, a part of the muscle may bulge out (balloon). If it does, the heart does not pump as well. You may have shortness of breath, pain or irregular heartbeats. In surgery, the bulge is cut out or patched.
To get to your heart during surgery, an incision may be made in the center of the chest. It may run from below the neck to the middle or bottom of the breastbone (sternum). Or, your incision may only cover part of the breastbone. The breastbone is then cut apart. After surgery, the breastbone is put back together by wires, but you most likely will not feel them. These wires don’t have to be removed even after the breastbone heals. In some cases, the incision may be made on the side of the chest. (When the aortic valve is replaced through a catheter, the breastbone is not opened.) Your skin incision is sewn, stapled or glued together and covered with a bandage.
Incisions* are painful for a few days and may remain sore for a few weeks, but there are ways to get relief. Be sure to let your nurse know if you are in pain. As you move around and get out of bed after surgery, you will find that your incisions bother you less.
* If you are having coronary bypass surgery, you may have both chest and leg or arm incisions.
If you have a few days or weeks to get ready for heart surgery, this is the time to take very good care of yourself. Plan to:
eat well
rest between activities
walk or do the exercise allowed by your doctor
quit smoking
limit alcohol use
Try to eat a variety of healthy foods each day even if you aren’t hungry. It’s important for your body to get enough vitamins and protein. Eating well speeds healing, and you will be less tired after surgery.
Don’t let yourself get too tired before surgery. The more rested you are, the stronger your body will be. Visitors mean well. They care about you and want to see how you are doing. If visitors or phone calls tire you, tell your friends that rest is an important part of your care. They will understand. About 2 short visits a day may be enough for you. And don’t be afraid to excuse yourself from company when you feel tired and need to rest.
Walk or do whatever exercise your doctor suggests. This helps relax your body and tone your muscles. Walk on flat surfaces at an easy pace. Stop any exercise if you notice signs of your heart problem. Call your doctor if they do not go away.
Smoking cigarettes, cigars, pipes and using smokeless tobacco cause damage to the heart and lungs. These:
raise blood pressure
make your heart beat faster
narrow your coronary arteries and smaller blood vessels
Not smoking is one of the best things you can do for your body before any kind of major surgery. Stopping for even a short time helps. You will breathe better, and your heart won’t have to work as hard.
It’s really hard to quit smoking when you are anxious or under stress—like before surgery. Here are some tips that may help you quit:
Take it one day at a time. Ask family and friends not to smoke when they are with you. When you want to smoke, do something else. Go for a walk, or do something with your hands.
Learn to relax. Plan time to be alone. Read a book, listen to music or just sit and listen to the sound of your breathing.
Cut down on coffee, alcohol and other drinks that you are used to having a smoke with.
Get up from the table as soon as you are done eating. This helps if you are used to smoking right after a meal.
If you have been a patient before, you know something about hospitals. If not, it may be very strange at first. It’s not easy being a “patient,” but knowing these things ahead of time can help you.
Some patients are admitted to the hospital the morning of surgery; others a day or so before. Be sure you know:
date and time to check into hospital
where to check into hospital
time of surgery
Your nurses can take better care of you if they know:
how to contact your family
any foods you don’t like or food allergies you have
any unusual reactions or allergies to medicines or test dyes
about any vision or hearing problems
who will be at home with you after surgery
anything about your family, home or work that you would like to share
name and number of your primary care doctor
Your family should tell your nurses: how they can be reached who will speak for you
If this is your first time in the hospital, you may want to ask about: times for medicines how to use the call light how your bed or special chair works where bathrooms are how to use the phone and TV
Before surgery, these tests may be done:
electrocardiogram (ECG)
echocardiogram (ECHO)
chest X ray
blood and urine tests
Several people will ask you questions about:
other medical problems or surgeries
your latest symptoms
allergies to foods or medicines
You will need to know the names of any medicines you are taking, exactly how much and when you take them. This includes cold medicines, vitamins, herbal supplements, skin patches and aspirin. Bring your medicines, or a current list of them, to the hospital with you.
NTG
water pills
If you are taking an anticoagulant (a blood thinner such as warfarin), aspirin or aspirin-product, ask your doctor about stopping them 5-7 days before surgery. Other medicines may also be stopped or changed. Be sure to take only what your doctor orders. Let your nurse know if you are having chest pain.
In some hospitals, a general “Consent for Treatment” is signed when you enter. More often, your doctor will ask you to sign a special consent form for your surgery. This explains what will be done, possible risks and possible results. If you do not understand what is being said, ask for more information.
By law, each patient must be asked if he has a living will or durable power of attorney. If you have one, bring a copy for your records. These legal papers, called advance directives, deal with choices about life support. If you need to know more, ask your nurse.
The hospital may also provide you with their privacy or HIPAA policies. These explain when, and to whom your medical information can be released.
There are a lot of things to do to get you ready for surgery. Here are some things to expect.
You may be asked to scrub your chest and maybe your legs 2 or 3 times with a special soap. This cleans your skin and removes germs. You can do this in the shower, tub or at the bedside.
Scrub gently but well enough to clean the skin. Be sure to rinse off all the soap when done. Don’t put powder or lotion on these areas.
If you feel tired, short of breath or have any pain or tightness while cleaning your skin, stop and ask for help.
Removing body hair also cleans the skin. You may be shaved or clipped from your neck to your knees or toes. The area and time of the shave/clip will depend on the kind of surgery and your doctor’s orders.
To help prevent infection, you may get an antibiotic before surgery.
A sleeping pill may be ordered to help you get plenty of rest the night before surgery.
Your stomach needs to be empty before surgery. This keeps you from vomiting during the operation. You should not eat or drink anything after midnight. But medicine, if ordered, may be taken with a few sips of water.
If your mouth gets too dry, you can rinse it with water, but DO NOT SWALLOW IT.
Be sure your family asks your nurse about these before you go to the operating room:
the time of surgery
where to wait while you are in surgery
progress reports—who will give them and how often
where you will be after surgery
when and how often they can visit after surgery
what to do with your valuables (watch, jewelry, keepsakes)
which items you can have in intensive care
what to do with your clothing, glasses, hearing aid, dentures, etc.
what they can do to help you recover
On the morning of surgery you should wake up early enough to shower, shave your face (if a man) and brush your teeth. You will be given a gown to wear to the operating room. You will be asked to remove:
dentures
hairpins
hairpieces
nail polish
makeup
all underwear
hearing aids
jewelry
contact lenses
artificial
body parts
glasses
You may be given medicine before your surgery. If so, be sure to go to the bathroom first, and then stay in your bed or chair. The medicine will make you feel relaxed and drowsy and make your mouth dry. Your family should sit quietly and avoid talking so you can relax and let the medicine work.
After you go to surgery, your family should take your things and go to the waiting area. You will not be returning to the same place after surgery. You will be taken to a recovery unit or to an intensive care unit (ICU).
You can be in the operating area for several hours. Heart surgery does not take that long, but time is needed to get you ready for the surgery and to complete it. The waiting time will seem long to your family, so they may want to bring something to do during this time.
When you begin waking up, it may seem like you just went to sleep. You will be aware of sounds such as alarms or bubbling noises. These are normal sounds made by the equipment around you. You will also hear people talking. Someone may be asking you questions or telling you that your surgery is over.
Everyone has some pain after surgery, and for each person it will be different. The first few days are the worst. Pain medicine will be ordered and should be taken when needed. It lets you rest and move around with more ease.
Pain medicine works best if you do not wait too long to ask for it. If you don’t let your nurse know you are hurting, she or he may think you do not need or want medicine.
Your family may be surprised when they first see you after surgery. They will be less frightened if they know that you may:
look pale and feel cool to the touch
shiver and have a swollen face
Your family can touch you, hold your hand or kiss you. They may share greetings from other family members or friends, but at first, visits should be very brief. You will begin to look better in just a few hours and will improve each day.
When your family leaves after a visit, they should tell you and your nurse where they can be reached and when they plan to be back.
Later, it may help if your family reminds you of the time of day. It is easy to lose track of time while in the hospital.
As you get stronger, your family can be more involved in assisting with your recovery. They can help you with some of your daily activities such as walking and bathing. This will also help you and your family feel more comfortable with your care when you get home.
A lot of equipment is used to watch and care for your body during and after surgery. It: helps you breathe measures the pressure and function of your heart checks your blood pressure measures your heart rate and rhythm checks how your kidneys are working
After surgery, you will still be connected to much of this equipment. This does not mean that things are not going well. The equipment checks how your body is working. Even with all this equipment, you will be able to move in bed. You will be very sleepy, but a nurse will help you turn and change positions.
While you are asleep in surgery, a breathing tube will be put through your mouth into your windpipe. It connects to a machine called a ventilator. This machine breathes for you during surgery. The breathing tube is removed when you are awake and can breathe on your own again. This usually happens within a few hours after surgery.
When you first wake up, this tube will still be in your throat. It will be taped to your face and may feel uncomfortable. You may even think that you can’t breathe. You can, try to relax and let the machine breathe for you.
You won’t be able to talk while this breathing tube is in place, but you will be able to nod “yes” or “no” when questions are asked.
Your nurse will suction mucus from your lungs and mouth through this tube. This will be done by putting a long, thin tube into the breathing tube. It will be unpleasant and will cause a “choking or coughing” feeling. But it is quick and is needed to clear your lungs.
When the breathing tube is removed, you will receive oxygen through a mask or nasal prongs. You may be hoarse or have a sore throat. This will get better in a few days.
These are also used during surgery and right after, but you won’t need them for very long.
arterial line—placed in a wrist artery; used to check blood pressure and draw blood samples; keeps you from being stuck every time blood is needed for testing
pulmonary artery catheter—placed in a neck vein; measures the pressures in your heart
IV’s (intravenous)—put in your veins before you are put to sleep; lets you receive fluid and medicine; stays in place after surgery until you are taking liquids and food by mouth and do not need it for medicines
heart monitor—connected to your chest by sticky pads (electrodes); records your heart rate and rhythm at all times; as you move around in bed, alarms on this machine may go off; your nurse is checking it, so do not worry about this
chest drainage tubes—placed in your chest during surgery if needed; drain the blood and fluid that collect in the chest after heart surgery; taken out after surgery when drainage stops
bladder catheter—a small tube put in your bladder to collect urine; shows how your kidneys are working; while it’s in, you may feel like you have to urinate, but it’s catching your urine; taken out when you can get out of bed to use the bathroom or bedside commode
When the catheter is taken out, you may feel some burning when you first urinate. Let your nurse know if this keeps up.
temporary pacemaker wires—thin wires attached to your heart; can be connected to a pacemaker to change your heart rate as needed; these wires are easily taken out when no longer needed
Your goal after surgery is to get back to normal as soon as you can. Things will move quickly when the breathing tube is out. You will begin to eat ice chips and drink sips of liquid. If these do not make you sick, you may begin to eat solid foods the next day. Try to eat the food that is served even if you don’t feel like it. A wellbalanced diet speeds healing.
When you no longer need constant care, you will be moved to another area. This may be done the day of surgery or within a few days after surgery. You will begin doing deep breathing and coughing exercises until your lungs are clear.
You will start being more active. First, you will be turned from side to side. When you are strong enough, you will be helped to the side of the bed and then sit in a chair. Your nurses will help you move as soon as it is good for you.
As you begin moving around, you will notice that your incisions (chest and leg or arm) are not as sore. If they still bother you, these will help:
change positions a lot
take pain medicine
raise your legs (if swollen)
Your activities will go from sitting on the side of the bed, to sitting in a chair, to walking in your room, to walking in the hall. At first you will need help. As you get stronger, you can move about on your own.
Getting out of bed is easier if you: raise only the head of the bed so that it’s upright move closer to the edge by rolling over on your side swing your legs to the floor and push your upper body up with your elbow; use the side rails to help pull yourself up (But not for total support of body weight.)
sit on the side of the bed for a couple of minutes to make sure you will not be dizzy
stand up and put both feet on the floor (Let your nurse know if you need help.)
Feeling anxious or scared before and after your surgery is common. Learning to relax is one way to help you feel calm and get back to normal faster. When you relax your mind and body, you will find that it is easier and feels better to get out of bed and to walk. You may also find that you have less pain and are able to sleep more soundly.
One of the simplest and best relaxation exercises is controlled breathing. When you think about your breathing, you will not think about more stressful things. You may want to practice before your surgery. Once learned, you can use this skill anywhere or anytime.
To practice controlled breathing:
Find a quiet place where you will not be disturbed. Choose a comfortable position.
Close your eyes and think of yourself in a place where you feel safe and secure.
Breathe slowly and easily.
Inhale quietly through your nose to a count of four. Hold for several seconds, then exhale through your mouth to a count of six.
As you breathe out, let your muscles relax and let go of the stresses of the day.
Two important things to do after surgery are deep breathing and coughing exercises. These help clear your lungs of mucus.
Mucus collects in the lungs during any major surgery. If it stays in the lungs, it can cause pneumonia and other health problems. You need to cough up as much as you can. Deep breathing opens up the tiny air sacs in the lungs. Coughing helps bring up the mucus.
These exercises will not be much fun, but the more you do them the quicker you will recover. Practicing before surgery will help you do them better. They won’t harm your incision, but you may hurt when doing them. If you have pain, ask your nurse for medicine.
You may do these exercises in a bed or chair. If in bed, raise the head of the bed (not the knee part) until you are sitting. Bend your knees to relax your stomach muscles. Hold a pillow or folded blanket firmly against your incision. Stay like this 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. Then do this:
1. Breathe in slowly through your nose while counting to 2. Your rib cage should expand as your upper chest and shoulders relax.
2. Breathe out slowly through your mouth.
3. After several deep breaths, breathe in slowly through your nose. Open your mouth, stick out your tongue and cough hard 3 times as you breathe out.
Repeat step 3 several times.
A device called an incentive spirometer is often used for deep breathing exercises. It will give you feedback about how well you are taking deep breaths. Slow, deep breaths are important in opening your airways and expanding your lungs. You will be taught how to do this.
Leg exercises
Press
feet against the foot of the bed. Turn
Take several short walks between times of rest. This keeps you from getting too tired while you are building your strength. Your posture needs to be good, so don’t slump even if you are sore. This gives you better balance and helps you breathe more deeply, too. Be sure to wear walking shoes with non-skid soles that fit well and feel good. Talk with your nurse before you walk alone.
support stockings
Your doctor may order support stockings. These aid blood flow and help reduce swelling in your legs. They should fit snugly. If they roll down or you notice marks on your legs when you take them off, let your nurse know. They may be too loose or too tight.
When you get out of bed, put on walking shoes with non-skid soles. Stockings are slippery if you do not wear shoes with them.
It will feel better to sit in a chair with a firm back than to sit on the side of the bed for a long time. Pillows under your arms will also make you feel better since they keep your shoulders from drooping.
Do not cross your legs. This puts pressure on the veins under the knees and slows blood flow. If your legs or feet swell, you should put them on a chair or stool. The stool or other chair should be higher than the one you are sitting in.
Several days after surgery you have done it all. You’ve coughed and taken more deep breaths than you wanted to. You’ve exercised your legs, moved around and gotten back your appetite. Then comes a touch of the blues. This may not happen to you, but if it does, do not be ashamed.
It is common for people to cry more easily or be more emotional after any major surgery. It’s also common to have bad dreams or trouble remembering or keeping your mind on something. These things are all related to anesthesia, medicines and loss of sleep. This will most often pass in 4 to 6 weeks. If it does not pass, tell your doctor.
As you rest, recover and get your strength back, you will feel that you are doing better each day.
Before you leave the hospital, someone will talk with you about what you should do in your first weeks at home. It will be a good time to:
enjoy the luxury of a nap
take one day at a time
build up your strength slowly
There is no set time for recovery, but it most often takes up to 4 to 6 weeks. After you get home, you will start doing more of your normal activities and will feel stronger every day. You will know how fast you can go and how much you can do by how you feel. Don’t rush it. Enjoy this time of healing. It may be the best thing you can do for yourself and those who love you.
As you think of other things to ask, use this space for notes.
Academy of Nutrition and Dietetics
120 South Riverside Plaza, Suite 2190
Chicago, IL 60606-6995
1-800-877-1600
eatright.org
American Heart Association National Center 7272 Greenville Avenue Dallas, TX 75231
1-800-AHA-USA1 (242-8721) heart.org
National Cancer Institute Quit Smoking Line
1-877-448-7848
Pritchett & Hull Books
The Active Heart (cardiac rehab)
Angina
Blood Pressure Control
Chill Out! and Control Stress
Exercise for Heart & Health
It’s Heartly Fare (nutrition)
Moving Right Along After Heart Surgery
Off the Beat (dysrhythmias)
Ready to Quit (smoking)
The Sensuous Heart (sex after heart attack or heart surgery)
A Stronger Pump (heart failure)
Wake Up Call (risk factors/heart disease)
