Prepare staff for cardiac surgery patients
Agency develops community-based program
Elkhart (IN) General Home Care began to focus on treating cardiac patients after the local medical community decided to create a new open-heart surgery program.
"We did not have a program in place. We were having to send our open-heart patients to South Bend," recalls Judy Rayhill, RN, staff development coordinator of the hospital-based, full- service agency that serves the northern part of Indiana and the southern part of Michigan.
Local physicians met with administrators and decided to set up a community-based program for open-heart surgery patients. The program, which focuses on extensive patient education and home care services, includes angioplasty and bypass surgery.
The home care agency will meet with each patient within 24 hours of the patient's discharge from the hospital. The program calls for home care nurses to see patients for four visits, following a clinical pathway developed by a committee of hospital nurses, physicians, pharmacy experts, and other specialists, Rayhill says. She taught nurses to handle each visit in this way:
o Visit 1:
The visit lasts about an hour, beginning with the nurse's assessment of the patient's home. The nurse makes sure the patient has a thermometer and working scales. "We demonstrate proper incision care for the chest incision and the leg incision," Rayhill says. "We are reinforcing the teaching the patients received before surgery."
Nurses need to make sure the patients know the signs and symptoms of infection. "They are all 'yes' and 'no' responses on that first visit," she says. "Either patients know it, or they don't, and if they do not, then we work with them until it is a'yes' response."
Nurses teach about medications, covering the dose, frequencies, purposes of medications, side effects, and interactions with other medications and foods. "We make sure they have the means to fulfill their medication requirements financially, and if not, then we call in a social worker."
Next, the nurse asks the patient about signs of nausea. If a patient is on fluid restriction, the nurse will reiterate that fluids should be limited for the patient's own safety. "We talk about their reporting of weight loss and the importance of an elevated temperature being reported," Rayhill adds.
Finally, the nurse will assess the patient's comprehension and ask if the patient remembers how to check the pulse or apply the compression stockings that are used to help with circulation. "Although it sounds like a lot to cover, what we are doing is confirming that they remember these previously taught steps."
Patients are given a daily log to write down their activities, exercise, and pulse rate.
o Visit 2:
This visit typically takes place on the third day after discharge. First, a nurse reviews the exercise and temperature logs to make sure the patient is doing the exercises and recording them correctly. "If not, then we review the importance of their doing it correctly, and we teach them how," Rayhill says.
The nurse confirms that the patient is taking medication and tolerating it without signs of nausea. "We also make sure their appetite is getting better," she says.
o Visit 3:
This visit takes place on the seventh day. "On the third visit, if everything goes as planned, then we remove the leg staples. If there's been a weight gain or temperature increase, we just ask about it."
The nurse confirms that the patient is using the machine that measures how well he or she can inhale. By watching the patient use the machine, the nurse assesses whether post-operative complications with pneumonia are developing.
Again, the nurse covers the disease process, nutrition, hydration, and exercise. The nurse also goes over the patient's prescribed diet and makes sure the patient understands about fat-free, salt-free foods. Then the nurse assesses whether the patient has the right hydration balance and is progressing with the daily walking program.
o Visit 4:
This last home visit takes place after the patient has been examined by a physician, typically on the 10th or 14th day after discharge from the hospital.
The home care agency informs the physician how the patient's incision is healing, whether the patient has had any changes in temperature or any weight gain or loss. The home care agency also documents whether the patient has achieved the goal of walking seven to 10 minutes four or five times a day without shortness of breath or chest pain. The physician sends the home care agency any changes in the course of action or pathway.
"Our goal for the patient is that at the end of the visits, the patient will understand and notify the physician of any chest pain, elevated weight gain, problems with tolerating food, changes in sleep patterns, and signs of depression," Rayhill says.
The nurse typically discharges the patient on the fourth visit, and then he or she is admitted to cardiac rehabilitation.
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