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🏥 Patient Assessment — Bharat K. Bhakare

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1. HEALTH HISTORY

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2. PHYSICAL ASSESSMENT (Head-to-Toe)

🔹 General Appearance

• Middle-aged male, appears anxious/distressed
• Pallor may be present; diaphoresis possible

🔹 Vital Signs (Baseline)

🔹 Cardiovascular System

• Chest pain: left-sided, radiating to left shoulder (typical anginal pattern in TVD)
• Auscultation: S1, S2; check for S3/S4 gallop (indicates LV dysfunction), murmurs, rubs
• JVD (Jugular Venous Distension): assess for heart failure signs
• Peripheral pulses: radial, femoral, pedal bilaterally
• Capillary refill time (<2 sec)
• Peripheral edema: bilateral lower limbs

🔹 Respiratory System

• Assess for dyspnea, orthopnea, PND
• Auscultation: clear fields vs. basal crepitations (pulmonary edema)
• Respiratory effort, use of accessory muscles

🔹 Abdomen (Critical — Given Exploratory Laparotomy Planned)

• Inspect: distension, visible peristalsis, scars
• Auscultate: bowel sounds (present/absent/abnormal)
• Palpate: tenderness, guarding, rigidity, hepatosplenomegaly, masses
• Percuss: tympany vs. dullness, shifting dullness (ascites)
• PR examination if indicated
• Document symptoms: nausea, vomiting, altered bowel habits, melena, hematuria

🔹 Neurological

• Level of consciousness (GCS)
• Orientation to time, place, person
• Motor/sensory deficits (pre-existing or new — relevant for on-pump CABG)

🔹 Musculoskeletal

• Mobility, grip strength
• Saphenous vein and radial artery patency assessment (graft harvest sites for CABG)

🔹 Integumentary

• Skin integrity, wound sites, bruising, IV access sites
• Signs of peripheral vascular disease

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3. DIAGNOSTIC INVESTIGATIONS

🔬 Laboratory Investigations

🫀 Cardiac Investigations

🔍 Abdominal Investigations (Pre-Laparotomy)

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4. NURSING DIAGNOSES (Pre-operative)

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5. PRE-OPERATIVE NURSING CARE PLAN

🎯 Priority Goals

1. Stabilize cardiac status and prevent further ischemia
2. Optimize patient's physical and psychological readiness for dual surgery
3. Prevent complications (arrhythmias, heart failure, abdominal deterioration)
4. Ensure informed consent and patient education

🩺 Nursing Interventions

Cardiovascular Monitoring

• Continuous cardiac monitoring (ECG telemetry)
• 12-lead ECG on admission and as needed
• Monitor vitals every 1–2 hours
• Oxygen therapy: 2–4 L/min via nasal cannula to maintain SpO₂ ≥95%
• IV access (2 large-bore peripheral cannulas)
• Administer prescribed medications: nitrates, beta-blockers, antiplatelet agents, statins
• Maintain IV heparin if indicated (per cardiologist order)

Pain Management

• Assess pain using NRS (0–10) every 4 hours and PRN
• Administer prescribed analgesics (morphine, nitrates)
• Position: semi-Fowler's (30–45°) for comfort
• Reduce physical and emotional exertion

Pre-operative Preparation

• NPO (Nil Per Os) instructions: 6 hours solid food, 2 hours clear fluids
• Bowel preparation as per surgical protocol (for laparotomy)
• Skin preparation: shaving/clipping of chest and abdomen
• Blood grouping, cross-matching, and reservation of packed RBCs (4–6 units)
• Baseline documentation of all investigations
• Foley catheter insertion pre-op
• Pre-op antibiotics as prescribed

Psychological Support

• Explain both procedures (CABG + Exploratory Laparotomy) in patient's language
• Address concerns about surgery, anesthesia, recovery
• Ensure informed consent obtained
• Involve family members in counseling
• Refer to chaplaincy/counseling if needed

Patient & Family Education

• Explain post-op ICU stay and expected equipment (ventilator, drains, catheters)
• Deep breathing exercises and incentive spirometry training
• Coughing technique with sternal support post CABG
• Post-op mobility and rehabilitation goals

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6. RISK STRATIFICATION

Cardiac Risk — HIGH

• TVD with symptom duration >6 days
• Age 58, male
• Dual major surgery planned

Surgical Risk — VERY HIGH

• Simultaneous CABG (open heart, cardiopulmonary bypass) + Exploratory Laparotomy
• Increased bleeding risk, hemodynamic instability, prolonged anesthesia

Risk Scoring (to be calculated):

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7. MULTIDISCIPLINARY TEAM INVOLVEMENT

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8. EXPECTED POST-OPERATIVE OUTCOMES

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Clinical Note: The combination of CABG and exploratory laparotomy in a single operative setting is a complex, high-risk undertaking. Thorough pre-operative optimization, multidisciplinary coordination, and meticulous ICU post-operative care are critical for a favorable outcome. The exploratory laparotomy indication must be clearly documented (e.g., acute abdomen, vascular emergency, bowel pathology) as it directly influences operative sequencing and risk.