FORTIS HOSPITALS
14, Cunningham Road,
Bangalore - 560 052.
Tel: 91 - 80 - 4199 4444.
E-mail: care.cg@fortishealthcare.com
PHASE OF CARE PRE - ADMISSION (OPA):
CARE PATHWAY - CABG
TICK ( ) FOR UNDONE / DONE RESPECTIVELY
DATE:
Activity M E N
Assessment Counseling of the patient regarding the surgery
Explainregarding the surgery.
Anaesthesia fitness & consent.
Assessed by consultant - Care to continue as pathway
Check for Investigation report.
Assessed by Anaesthetist, anaesthesia type discussed & recorded.
Investigations CBC, FBS
Sr. Creatinine
ECG, X - Ray.
2D ECHO.
HIV, HBSAg. HCV.
Angiography report CD or angio flim to be made available
Cross consultation - Pulmonologist nephrologist etc.
NURSING ASSESSMENT :
Baseline vital signs
Check weight abdomonial girth / room air SPO2
Explain anxieties.
Explain discharge date.
remind about medication / self-medication
OUTCOMES
Patient demonstrates understanding of :
Plan of care.
Fasting protocol.
admission Day.
Page - 1 FHL/CG/CARD/001
PHASE OF CARE PRE - ADMISSION (OPA) :
CABG / VALVULAR Care Pathway
DATE
M E N
Assessment MEDICAL ASSESSMENT
Counseling of the patient & the relative regarding the Surgery.
Explain regarding the surgery.
Obrain written Consent regarding surgery.
Investigations :
* ECG
* 2D ECHO
* CBC
* Sr. Creatinine
* BUN, Sr. Electrolytes, RBS
* HIV, HBSAg, HCV.
* Chest X - Ray
* Abdomen / Carotid / Radial Doppler study
Angiography report films
Anaesthesia Consent and Anaesthesia fitness
Physiotherapy Reference any special investigations (thallium scan)
NURSING ASSESSMENT :
Baseline vital signs
Check weight abdominal girth / room air SPO2
Explain Anxieties.
Discuss Discharge Date.
Explain about Fasting
Remind about Medication / Self Medication
Explain about fasting
OUTCOMES :
Patient demonstrates understanding about :
Plan of Care.
Fasting protocol.
Admission day.
Page - 2
PHASE OF CARE PRE - ADMISSION DAY
DATE
M E N
1. MEDICAL ASSESSMENT
Ensure Surgery is Explained & Understood.
Obtain Consent ........................... High risk
......................... Anesthesia consent and fitness.
Check blood investigation Reports.
* CBC
* BUN
* Sr. Creatinine
* RBS
* 2D ECHO
* Angiogram Report.
* X - Ray Chest
* HIV, HBSAg, HCV.
* PTT, PT with INR.
* Lipid Profile
* Urine Analysis
Administer pre - operative medication / Antibiotics as per hospital policy
Blood Grouping & Cross matching (Arrange blood pints as advised)
Assess need for mammary support.
Physiotherapy reference.
2. NURSING ASSESSMENT :
Baseline vital signs
Check weight
RBS if suggested
Explain team nursing
Discuss Discharge requirement.
Explain regarding pain management.
Assess / for self - medication.
Explain Aids that may be used post - operatively
Endotracheal tube, Suction, Drains, Oxygen therapy.
Ventilator, monitors, Central Lines, Arterial Lines.
Foleys Catheter. Rectal Temperature probe / epidural catheter /
epicardial pacing leads.
Skin Preparation (Microshield Bath). Inspect skin for abrasion /
infection
Page - 3
PHASE OF CARE - ADMISSION DAY
DATE
M E N
Bowel Preparation
Inform SICU staff to keep bed ready
Teach deep breathing and coughing exercises incentive spirometry
Explain visiting facilities.
Explain about inability to communicate about calling bell to seek attention
Explain about fasting.
Explain about ICU routines.
3. PHYSIOTHERAPY :
Introduction of physiotherapist
Discuss cardiac rehabilitation process involving patient and family members.
Check respiratory function.
Remind patient of precaution and need of deep breathing and coughing exercises.
Teach limb exercises to be done post operatively
4. OUTCOMES :
Patient demonstrates understanding
Proposed Surgery
Immediate postop events
Fasting protocol
DATE VARIANCES ACTION TAKEN SIGN
AM PM NIGHT
NURSES NAME :
Page - 4
PREOP CHECK LIST FOR CABG / VALVULAR SURGERY
DATE
M E N
Please tick appropriate box if action competed.
1. Identification label checked. All details correct.
2. Operation consent form fully completed (Signed by patient & consultant)
3. Prosthesis / loose teeth / crowns identified & removed (specify) :
(e.g. : Dentures / contact lenses / hearing aids / spectacles)
4. Nail polish / make up removed
5. Jewellery removed
6. Operative area prepared / marked (specify):
7. No signs of any skin abrasions
8. Last food taken at : ............................ Last drink taken at ............................... (Time & Date)
9. Patient passed urine at : ...............................(Time & Date) Passed stool at : .......................
10. Complete notes (includes baseline observations) accompanying patient
11. Please tick box if following tests / results available :
ECG X-Ray film / scans
12. Routine blood results available
other blood tests available (tick if results available)
other blood tests (specify) :
13. Special needs noted :
Hearing difficulties Visual defects Language barriers
Other (specify) :
14. If female - patient states there is no possibility that she is pregnant
Male patient there N/A
15. Pre - medication given & recorded
Ward Nurse Name & Time :
Theatre staff Name & Staff :
Page - 5
PHASE OF CARE - IMMEDIATE POST OP
CABG / VALVULAR Care Pathway
DATE
M E N
POST - OP PHASE (done every 15minutes / recovery) 1 hourly / SICU)
1. MEDICAL ASSESSMENT DONE
2. NURSING ASSESSMENT
ACCESS SITES - INTRODUCER YES / NO
- TEMPORARY PACER YES / NO
- EPICARDIAL PACING WIRES YES / NO
ACCESS INCISION SITE SVG YES / NO
RAG YES / NO
CHEST TUBES...........1..............RT PLEURAL 3
RETROSTERNAL - LT PLEURAL 4 RETROSTERNAL
STERNOTOMY YES / NO
THORACOTOMY YES / NO
3. HAEMODYNAMIC MONITORING
TEMPERATURE >98 F & <100 F
PULSE > 60 & <120 / MIN
B.P. SYSTOLIC > 90mmHg < 160 mmHg
INTAKE & OUTPUT
URINE > 30 CC/hr
DRAINS NOT MORE THAN 100 ml/hr
4. BLOOD INVESTIGATION
CBC
Sr. Electrolytes
Bun. Creatinine
PTT with INR
X-Ray Chest, ECG
ABG
ARTERIAL LINE MONITORING
5. BLOOD SUGAR
6. CVP MONITORING
7. OBSERVE FOR S/S OF MI & ECG CHANGES CARDIAC ENZYMES
8. CONTINOUS ECG MONITORING
9. BLOOD TRANFUSION & FFP
Page - 6
PHASE OF CARE - IMMEDIATE POST OP
DATE
M E N
10. RESPIRATORY SYSTEM
Check ET Tube Placement
Assess respiratory status
Endotracheal suctioning 4 hrly nd PRN
wean to extubate as per CVTS protocol specify hours
ABG before weaning
Administer Oxygen ------------% VIA CPAP / face mask nasal prongs
Incentive spirometry post extubation
Nebulisation
Chest X - ray following extubation
11. WOUND ASSESSMENT & CARE
Check for bleeding at Surgical site
Chest Drain - AMT of Deain, CLOTS,
Consistency, bubbling
Measure Drain 1 hrly
Milking 1 hrly
Report blood loss > 100 ml / hr
Zero Drains at 6 a.m.
12. MEDICATIONS
Continue PCAS in progress / as ordered
IV Fluids
Inotropes
Vasodilators
Antiarrhythmic
Diuretics
13. NEUROLOGIC ASSESSMENT
GASTROINTESTINAL ASSESSMENT
NUTRITION
As per physicians order
Progress activity as per condition
Bed rest / position 2 hrly & PRN
Dangle 2 hrs post Extubation
Up in chair 4 hrs post Extubation / as tolerated
Ambulate 8 hrs post Extubation
Page - 7
PHASE OF CARE - IMMEDIATE POST OP
CABG / VALVULAR Care pathway
DATE
M E N
15. HYGIENE
Assist with Hygienic needs -
Mouth care ..........................................
Sponge Bath ........................................
16. ELIMINATION
Bowel Movements
Assist with Elimination needs
17. PHYSIOTHERAPHY
18. OUTCOMES :
Gaemodynamically Stable
Pain Controlled
Wound Clean & Dry
Temperature Maintained <38C
Activity started as tolerated
Diet & Fluid Tolerated
DATE VARIANCES ACTION TAKEN SIGN
AM PM NIGHT
NURSES NAME :
Page - 8
PHASE OF CARE - POST (DAY - ONE) LOCATION - SICU
DATE
ACTIVITY M E N
1. MEDICAL ASSESSMENT
2. NURSING ASSESSMENT
Haemodynamic Monitoring
TPR * BP every hrly - till in SICU
Arterial presure monitoring - MAP
LAP
PA P
PA WP
Intake / output every hrly
ECG Monitoring (continous)
Assess the lines : Arterial
Central
Peripheral
Epicardial pacing wire
3. RESPIRATORY
Wean Oxygen as per saturation SPO2 -
Assess Breath sounds
Chest PT
Incentive spirometry
Nebulisation
4. WOUND SITE
Surgical site --------- watch for haemorrhage /
Soakage ------------Y / N
Dressing changed ---------------------- Y / N
Arterial graft - : -
Radial Elevated
Saphenous TED
Check sensation, Circulation & Movements
Chest tube present ------------------- L WS
water seal
D/C
Amount / type of Drain Air Leak
Epicardial pacing wire -------- Y / N .................. D / C ........................... dt.
Central line dressing done ---------------- Y / N
Page - 9
PHASE OF CARE - POST OP (DAY - ONE) LOCATION - SICU
CABG / VALVULAR Care Pathway
DATE
5. INVESTIGATIONS M E N
ECG, Chest X - Ray following chest tube removal
Blood Investigations as advised
ACTIVITY
POST OP (DAY - ONE) CONTD.)
6. MEDICATION
Continue PCA’s
I. V. Fluids if Indicated
Taper Nikoran ......................... Y / N D/C. .................... Y / N
Taper NTG .............................. Y / N D/C. ..................... Y / N
Taper Inotropes...................... Y / N D/C. .....................Y / N
Continue Antibiotics
Continue Anticoagulants oral Heparin / None
Continue Aspirin Clopidogrel / None
Continue Beta Blockers ACEI / Statin / None
Any Other Medication
7. TREATMENT / PROCEDURES
Remove Arterial Line (before shifting to Wards)
Remove Foleys cath (before shifting to Wards)
Surgical site dressing changed (before shifting to Wards)
CVT site dressing changed (PRN)
8. HYGIENIC NEEDS
Assist with Hygienic Needs
9. ACTIVITY
Increase in activity as tolerated
Out of bed to Chair (Twice a Day)
Ambulation with assistance
Limb Excercises of RAG Hand & SVG Leg
Encourage Movements to reduced risk of pressure sores / Bed Sores
10. NUTRITION
Diet as Tollerated
11. ELIMINATION
Ensure Bowel Opened
Urine Passed after Foley’s Catheter removed
Page - 10
PHASE OF CARE - POST OP (DAY - ONE) LOCATION - SICU
CABG / VALVULAR Care Pathway
DATE
12. PHYSIOTHERAPY M E N
ACTIVITY
13. OUTCOMES
Haemodynamically Stable
Pain Controlled
Diet as Tolerated
Wound Clean & Dry
Temperature Maintained below 30C
CSM Intact from Limb which Graft Taken
Ambulation as Tolerated
DATE VARIANCES ACTION TAKEN SIGN
AM PM NIGHT
NURSES NAME :
Page - 11
POST OP (DAY - TWO & THREE) LOCATION - SICU TO WARDS
CABG / VALVULAR Care Pathway DAY - 2 DAY - 3
DATE
ACTIVITY M E N M E N
1. MEDICAL ASSESSMENT
2. NURSING ASSESSMENT
Weight
TPR, BP 4 hrly PRN SPO2
I / O Chart
Central Line Y/N
Foley’s Catheter Y/N
Chest tube ...................... LWS................... Water Seal. ............... D/C
Amount of Drain ............................................
Type of Drain .................................................
Zero Drain at 6 a.m. Y/N
Peripheral Line Y/N
Epicardial Pacing Wire Y/N
3. PULMONARY ASSESSMENT
Assess Breath Sounds
Incentive Spirometry
Chest Physiotherapy
Deep Breathing & Coughing Exercises
Nedulisation
Wean O2 as per SPO2
4. WOUND ASSESSMENT
No Haemmorhage / Soaking / Oozing
Dressing Changed PRN
Assess Graft site for Redness
Pain
Warmth
Discharge
Chest tubes site Clean / Dry .....................................Y / N
Assess CVP Site
Inform SOS
Page - 12
POST OP (DAY - TWO & THREE) LOCATION - SICU TO WARDS
CABG / VALVULAR Care Pathway DAY - 2 DAY - 3
DATE
M E N M E N
5. ACTIVITY
Elevate RAG Hand
Exercises of Limbs
Teds for SVG Leg
OOB Tid
Ambulate as Tolerated
6. NUTRITION
Diet as Advised by Physician
7. INVESTIGATIONS
Test as per Physicians Order
ECG
X - Ray Chest
X - Ray Chest tubes present
X - Ray Chest tubes Remove
Blood Investigations as Ordered
8. ELIMINATION
Ensure Bowel Opened on 3rd Day
Passes Urine without Difficulty
9. TREATMENT / PROCEDURES
Chest tubes Removed
Dressing Done Surgical Site
CVT Site
Peripheral Site
Chest Belt after Chest Tube Removal
10. MEDICATIONS
PCAS
Diuretics
Beta Blockers
Aspirin
Anticoagulants
Antibiotics
Any Others Medication
11. HTGIENE
Assist with Hygienic Needs
Page - 13
POST OP (DAY - TWO & THREE) LOCATION - SICU TO WARDS
CABG / VALVULAR Care Pathway
DAY - 2 DAY - 3
DATE
12. PHYSIOTHERAPY M E N M E N
13. OUTCOMES
Pain Controlled
Wound Cleaned & Dry
Micturates without Difficulty
Bowel Opened
Temperature < 38C
Mobilised to Chair (Increased activity)
Diet Modified
DATE VARIANCES ACTION TAKEN SIGN
AM PM NIGHT
NURSES NAME :
Page - 14
POST OP (DAY - FOUR & FIVE) LOCATION - SICU TO WARDS
CABG / VALVULAR Care Pathway DAY - 4 DAY - 5
DATE
ACTIVITY M E N M E N
1. MEDICAL ASSESSMENT
2. NURSING ASSESSMENT
Weight (OD) 6 a.m.
TPR 4 hrly & PRN SPO2
BP 4 hrly & PRN
I / O Chart
Assess Peripheral Lines
Chest tube LWS.....................................................
Water Seal..........................................
D/C.....................................................
Amount of Drain ................................
Type of Drain......................................
Soakage .............................................
Assess CVP Site
CSM of Limb Intact
Assess Wound Incision site. ......................................................... Pain
............................................. Redness
Epicardial Pacing Wire D/C Y/N
3. PULMONARY ASSESSMENT
Assess breath Sound
Chest Physiotherapy
Incentive Spirometry (1 hrly while awake)
Nebulisation
4. ACTIVITY
Ambulate Around Unit TID / WARD / OD
Physiotherapy of Limbs
Increase activity as Tolerated
5. INVESTIGATIONS
As per Physician Order
Chest X-Ray
ECG
Blood Investigations
6. TREATMENT / PROCEDURES
Chest tubes Removed
Dressing Done
Consider D/C Pacing Wires
Teds for SVG Limb
Chest Belt
Page - 15
POST OP (DAY - FOUR & FIVE) LOCATION - SICU TO WARDS
CABG / VALVULAR Care Pathway DAY - 4 DAY - 5
DATE
M E N M E N
7. DIET
Diet as Advised
8. MEDICATIONS
PCAS
Diuretics
Beta Blockers
Anticoagulants
Antibiotics
Suppository for Bowel Opening
9. ELIMINATION
Ensure Bowel Opened
Assist with Elimination Needs
10. PHYSIOTHERAPY
ACTIVITY
11. OUTCOMES
Wound Clean & Dry (No infection)
Mobilised in Wards
Temperature <38C
Mobilise as per Normal Limitations
CSM intact
No DVT
DATE VARIANCES ACTION TAKEN SIGN
AM PM NIGHT
NURSES NAME :
Page - 16
POST OP (DAY - SIX & SEVEN) LOCATION -SICU TO WARDS
CABG / VALVULAR Care Pathway DAY - 6 DAY - 7
DATE
ACTIVITY M E N M E N
1. MEDICAL ASSESSMENT
2. NURSING ASSESSMENT
Weight (OD) 6 a.m.
TPR 4 hrly & PRN SPO2
BP 4 hrly & PRN
I / O Chart
Assess Peripheral Lines
Assess CVP Line
CSM of Limb Intact
Assess Wound Incision site
Chest Drain Y/N
Amount of Drain ..........................................
Type of Drain ...............................................
3. PULMONARY ASSESSMENT
Assess Breath Sound
Chest Physiotherapy
Incentive Spirometry (1 hrly while awake)
Nebulisation
Deep Breathing & Coughing Exercises
4. ACTIVITY
Ambulate Around Ward Twice a Day
Mandatary Stair Climbing under Physiotherapy Supervision
Physical Exercises of the Limbs
5. INVESTIGATIONS
As per Physician Order
Chest X-Ray
ECG
Blood Investigations
6. TREATMENT / PROCEDURES
Surgical Dressing Done
Chest Tubes Removed
TED’s for SVG Limb
Page - 17
POST OP (DAY -SIX & SEVEN)LOCATION -SICU TO WARDS
CABG / VALVULAR Care Pathway DAY - 6 DAY - 7
DATE
ACTIVITY M E N M E N
7. DIET
Diet as Advised
8. MEDICATIONS
PCAS
Diuretics
Antibiotics
Anticoagulants
Beta Blockers
Any Other
9. ELIMINATION
Ensure Bowel Opened
Suppository / Laxatives as Ordered
10. PHYSIOTHERAPY
Nursing : Train Patient / Relative regarding Administration of Insulin
where Applicable / Simple Dressing when Indicated
DATE VARIANCES ACTION TAKEN SIGN
AM PM NIGHT
NURSES NAME :
Page - 18
POST OP (DAY – EIGHT & NINE) LOCATION - SICU TO WARDS
CABG / VALVULAR Care Pathway DAY - 8 DAY - 9
DATE
ACTIVITY M E N M E N
1. MEDICAL ASSESSMENT
2. NURSING ASSESSMENT
Weight (OD) 6 a.m.
TPR 4 hrly & PRN SPO2
BP 4 hrly & PRN
I / O Chart
Assess Peripheral Lines / Removed on Discharge
Assess CVP Line / Remove on Discharge
CSM of Limb Intact
Assess Wound Incision site
Chest Drainage Removed
3. PULMONARY ASSESSMENT
Assess Breath Sound
Chest Physiotherapy
Incentive Spirometry
Nebulisation
Deep Breathing & Coughing Exercises
4. ACTIVITY
Ambulate Around Ward Three times a Day
Physical Exercises of the Limbs
5. INVESTIGATIONS
As per Physician Order
Chest X-Ray
ECG
6. TREATMENT / PROCEDURES
Surgical Dressing Done
Chest Tubes Removed
TED’s for SVG Limb
Chest Belt
7. DIET
Diet as Advised
Page - 19
POST OP (DAY - EIGHT & NINE) LOCATION - SICU TO WARDS
CABG / VALVULAR Care Pathway DAY - 8 DAY - 9
DATE
M E N M E N
8. MEDICATIONS
PCAS
Diuretics
Antibiotics
Anticoagulants
Beta Blockers
Any Other
HYGIENE
Assist with hygienic needs
9. ELIMINATION
Ensure Bowel Opened
Suppository / Laxatives as Ordered
10. PHYSIOTHERAPY
11. DISCHARGE HOME
No Problems Identified on Discharge
OPA’s Arranged (Suture / Clip Removal)
Ensure Discharge Summery Completed & Given to Patient
Post Procedure Advise Reenforced
DATE VARIANCES ACTION TAKEN SIGN
AM PM NIGHT
NURSES NAME :
Page - 20
