Running head: CARDIAC SURGERY TERMINOLOGY DOMAIN

Complications Following Emergent CABG:

Cardiac surgery Terminology Domain

Ken Bavier BSN, RN

Duke University School of Nursing

N409

Instructor: Dr. Linda Goodwin

Deb Molstad

I selected as my terminology domain, cardiac surgery of which I am very familiar, and that is attributed to the primary cause of death for Americans (American Heart Association, 2005 & American College of Cardiology, 2005). My one-page story described a patient situation where the patient developed an unusual complication post operatively that nearly led to the loss of his life. As I iterated over the domain terminology, I moved away from the focus of this patientÕs complication, and instead focused on normal patient evolutions and more common complications. The volume of terms that were revealed during the iterative phase was significant, and ultimately exceeded 400 items. This list is in no way exhaustive, but rather serves as a foundation for further review.

The cardiac surgery terminology domain borrows terms from many disciplines including cardiology, nursing, anesthesia, psychology, anatomy, and surgery. Compound terms are common, owing to the complexity of the patient and the treatments that they undergo. Current leadership in the develpoment of cardiac surgery and cardiology specific terminologies include the American College of Cardiology, the American NursesÕ Association, the Association of Operating Room Nurses, and the American Heart Association.

High level concepts noted in the development of this project included such areas as risk factors, symptoms, treatments, clinical services, environmental factors, diagnostics, anatomy and physiology, and complications. The organization of this domain could have been arranged differently to include a separate section covering equipment and pathophysiology though the current organizational schema developed logically from my early term list.

It is significant to note that the treatments, anatomy and physiology, and complications subsections could have included exponentially more terms though the more terms I added, the more it seemed like I was leaving the realm of cardiac surgery. The final term list was redundant with some of the earlier terms but contained such a significant number that I included it in itsÕ entirety next to the original lists rather than try to include the 300+ terms that developed during the brainstorming sessions with the mindmapping software. The folowing Excel chart reflects the evolution of the cardiac domain terminology project:

Meaningful Story Term	Additional Terms	Patient	Nurse	Physician	Subject Matter Expert Suggestions	Final Results Imported from MindManager
					Paramedic	Treatments
Intensive Care		X	X	X	Surgeon	Counseling
Post-op			X	X	Critical Care	Clinical
Surgery		X	X	X	Pulmonologist	Religious
Cardiac			X	X	Intensivist	Social Work
Patients		X	X	X	Ambulance	Medications
Complicated			X	X	EMT	Antiarrythmics
Emergently/Emergent			X	X	Visiting Hours	Cardizem
Nurse		X	X	X	Limited	Lidocaine
Recovery/Recovering		X	X	X	Generous	Adenosine
ER		X	X	X	Restricted	Cardioversion
Chest Pain		X	X	X	discretion	Countershock
MI			X	X	Stepdown	Anticoagulants
Crushing		X	X	X	Telemetry	Coumadin
Pressure		X	X	X	Cath Lab	Hirudin
Radiating			X	X	Operating Room	Heparin
EMS			X		OR	Plavix
EKG		X	X	X	Home	Ticlid
ST-Segment Elevation			X	X	Complications	Aspirin
Ectopic Beats			X	X	ER	ASA
Blood Pressure		X	X	X	CCU	Beta Blockers
Heparin			X	X	discharge	Lopressor
Dopamine			X	X	home	Esmolol
Nitroglycerine		X	X	X	rehab	Coreg
Cath lab			X	X	case manager	Tenormin
Coronary angiography				X	CCU Nurse	Calcium Channel Blockers
Heart cath		X	X		circulator	Cardizem
Triple vessel disease			X	X	ER Nurse	Norvasc
CABG			X	X	floor nurse	Procardia
Invasive line			X	X	scrub nurse	Calan
Swan Ganz			X	X	RNFA	Verapamil
Arterial Line			X	X	First Assist	Nitrates
IABP			X	X	CRNA	Imdur
OR			X	X	house staff	Isosorbide Mononitrate
Uncomplicated				X	resident	Isordil
Bypasses		X	X		family practice	Isosorbid Dinitrate
CICU			X	X	medicine	Nitro-Bid
Anesthesia		X	X	X	pulmonologist	Nitro-Dur
Vital Signs		X	X	X	intensivist	Nitro TTS (transdermal)
Hemodynamics			X	X	critical care	Nitroglycerine
Stable			X	X	cardiothoracic assistant	Paralytics
Extubated			X	X	perfusionist	Nimbex
Cannula			X	X	PA	Cisatricurium
Post-op Day			X	X	physician assistant	Norcuron
Discharge		X	X	X	surgeon	Vecuronium
Tachyarrythmia			X	X	medical cardiologist	Pavulon
Hypotension			X	X	interventionalist	Pancuronium
Fever		X	X	X	cardiologist	Anectine
Infection		X	X	X	cardiology	Succinylcholine
Lungs		X	X	X	anesthesia assistant	Sedatives/Amnesics
Chest Xray			X	X	MDA	Diprivan
Abdomen			X	X	anesthesiologist	Ativan
Radiograph				X	radiology technician	Versed
Inconclusive findings				X	radiologist	Haldol
Paralytic Ileus				X	angioplasty	Romazicon
Obstruction			X	X	PTCA	Flumazenil
Stool Softeners		X	X	X	stent	Vasopressors
Enema			X	X	drug eluting	Levophed
Activity		X	X	X	triple vessel disease	Dopamine
Weak		X	X	X	arterial	Neo-Sinephrine
Bedrest			X	X	venous	Phenylephrine
Commode			X	X	angiojet	Inotropic Agents
Exertion			X	X	wire	Epinephrine
Unresponsive			X	X	heart cath	Dobutamine
Pupils Dilated			X	X	chest xray	Primacor
Agonal			X	X	portable	Natrecor
House Staff			X	X	CT	Emergency Drugs
Fluids			X	X	CAT Scan	Amiodarone
Administered			X	X	MUGA Scan	Atropine
Levophed			X	X	digitizer	Epinephrine
Chest Compressions			X	X	PACS	Lidocaine
Respirations			X	X	radiograph	Magnesium
Ambu bag			X	X	film	Pronestyl
Re-intubated			X	X	xray	Vasopressin
Anesthesiologist			X	X	bladder pressure	Anti-Lipid
Respirator		X	X	X	permacath	Bile Sequestrants
Ventilator			X	X	sheath	Statins
Infarcted			X	X	pressure transducer	Lipitor
Bowel		X	X	X	ECG	Zocor
Peritoneum				X	EKG	Mevacor
Hemicolectomy				X	stress test	Lescol
Ileostomy			X	X	non-stress test	Pravachol
Antibiotics		X	X	X	EP studies	Crestor
Physician			X		vital signs	GI
					glucometer	Carafate
	Chest Tube		X	X	pulse oximeter	Histamine Antagonists
	Pacemaker	X	X	X	Hemoglobin	Zantac
	Dressings		X	X	calcium	Maalox/Mylanta
	Sutures			X	magnesium	Prevacid
	Foley Catheter	X	X	X	hematocrit	Protonix
	Colostomy	X	X		BUN	Pantoprozole
	Tape	X	X		creatinine	Prilosec
	Charting		X		potassium	Omeprazole
	IV	X	X		phosphorus	Enema
	Central Line		X	X	labs	Stool Softeners
	Pulses	X	X		smoking	Vitamins
	Bed bath		X		IDDM	Folic Acid
	Linen Change		X		NIDDM	MVI
	Reposition	X	X		type I	Multi-vitamin
	Call Light	X	X		Type II	Pain Medications
	Cardiac Monitor		X	X	diet-controlled	Morphine
	Pulse Oximeter		X	X	diabetes	Percocet
	Hopeless	X			stress	Fentanyl
	Pain	X	X	X	genetics	Demerol
	Grief/Grieving		X	X	cocaine	Toradol
	Hypothermia		X	X	marijuana	IV Fluids
	Morphine	X	X	X	THC	LR
	Pressure Transducer		X		heroin	Dextrose
	Hemoglobin		X	X	amphetamines	Normal Saline
	Glucometer	X	X	X	benzodiazipines	Wide Open
					alcohol	Keep Open
					street drugs	Antibiotics
					diet	Pulmonary
					chest pain	IncentiveSpirometry
					angina	Cough and Deep Breathing
					crushing	Intermittent Positive Pressure Breathing
					pressure	IPPB
					radiating	Oxygen Therapy
					ST	CPAP/BiPAP
					elevation	Nasal Cannula
					depression	Venturi Mask
					Shortness of breath	Non-rebreather
					SOB	Simple Mask
					DIB	Partial Rebreather
					Exertion	Ventilator
					symptoms	Assist-Comtrol
					racing	SIMV
					palpitations	T-Mist
					ectopic beats	Ambu Bag
					pain	Respirator
					weakness	Extubated
					weak	Positioning
					blood pressure	Physical Rehab
					stable	Cardiac Rehab
					grieving	Physical Therapy
					Hopeless	Occupational Therapy
					pulmonary	Exercise
					alveoli	Progressive
					bronchial	Activity
					vocal cords	Bedrest
					trachea	Surgery
					respirations	CABG
					mitral valve	MIDCAB
						OPCAB
						Traditional
						Valve Replacement
						AVR
						MVR
						TVR
						Multiple Valve Replacement
						MAZE Procedure
						Chest tubes
						mediastinal
						Pleural
						Pacemaker
						Suture
						Dressings
						Assistive Devices
						IABP (Balloon Pump
						VAD (Ventricular Assist Device)
						Ventilator
						Foley Catheter
						Chest Tube
						Pacemaker
						Temporary Transvenous
						Epicardial
						Permanent
						Biventricular
						AICD
						Nutrition
						ADA Diet
						Cardiac Diet
						TPN/Lipids (Hyperalimentation)
						Tube Feeding
						NPO
						Complications
						Arrythmia
						Asystole
						VT/VF
						Bradyarrythmia
						Tachyarrythmia
						Afib/Aflutter
						Atelectasis
						Awareness
						DVT
						Fever
						Hematoma
						Heparin Induced Thrombocytopenia
						Infarcted Bowel
						Malignant Hyperthermia
						MODS
						Pneumonia
						Post Op Bleeding
						Perioperative MI
						Renal Failure/Insufficiency
						Stroke/CVA
						Tamponade
						Decubitis Ulcer
						Confusion
						Oliguric
						Uncomplicated
						Anuric
						Agitation
						UTI
						"Pump Head"
						Wound Infection
						Nausea
						Pressure Ulcer
						Bowel Obstruction/Distended Abdomen
						Paralytic Ileus
						Obstruction
						Unresponsive
						Hypotension
						Infection
						Hypothermia
						Hyperglycemia
						Anatomy/Phsiology
						Pulmonary
						Lungs
						Alveoli
						Bronchial
						Vocal Cords
						Trachea
						Respirations
						Cardiac
						Mitral Valve
						Aortic Valve
						Left main
						LAD
						Tricuspid Valve
						Hilar
						Mediastinum
						RCA/Right Coronary artery
						Circumflex
						Bypass
						Pulses
						GI
						Abdomen
						Esophagus
						BM
						GU
						Urinary
						Output
						Integumentary/Skin
						Ecchymosis
						Wound
						Margins
						Sutures
						Neurological
						Alert and Oriented
						Dementia
						Alzheimers
						Aldrete Scale
						Sedation
						Pain control
						GCS
						Glascow Coma Scale/Score
						Symptoms
						Chest Pain
						Angina
						Crushing
						Pressure
						Radiating
						ST-Elevation
						ST-Depression
						Shortness of Breath
						SOB
						DIB
						Exertion
						Racing
						Palpitations
						Ectopic beats
						Pain
						Weakness
						Weak
						Blood pressure
						Stable
						Grieving
						Hopeless
						Risk Factors
						Smoking
						Diabetes
						Type I
						Type II
						NIDDM
						IDDM
						Diet-Controlled
						Stress
						Genetics
						Street Drugs
						Cocaine
						Marijuana
						THC
						Heroin
						Amphetamines
						Benzodiazepines
						Alcohol
						Diet
						Diagnostics
						Angiography
						Angioplasty/PTCA
						Stent
						Drug Eluting
						Triple Vessel Disease
						Arterial Sheath
						Venous Sheath
						Angiojet
						Wire
						Heart cath
						XRAY
						Chest Xray
						Portable
						CT
						CAT Scan
						MUGA Scan
						Digitizer
						PACS
						Radiograph
						Film
						Bladder Pressure
						Invasive Lines
						Swan Ganz
						Arterial Line
						CVC
						Permacath
						Sheath
						Arterial
						Venous
						Pressure transducer
						Non-invasive Tests
						ECG
						EKG
						Stress Test
						Non-Stress Test
						EP Studies
						Electrophysiology Studies
						Vital signs
						Glucometer
						Pulse oximeter
						Labs
						Hemoglobin
						Calcium
						Magnesium
						Hematocrit
						BUN
						Creatinine
						Potassium
						Phosphorus
						Clinical Services
						Nursing
						Case Manager
						CCU Nurse
						Circulator
						ER Nurse
						Floor Nurse
						Scrub Nurse
						RNFA
						First Assist/Assistant
						CRNA
						Physician and Extender
						Medicine
						House Staff
						Resident
						Family Practice
						Critical Care
						Pulmonologist
						Intensivist
						Cardiac Surgery
						Cardiothoracic Assistant
						Perfusionist
						Physician Assistant
						Surgeon
						Cardiology
						Medical Cardiologist
						Interventionalist
						Cardiologist
						Cardiology PA
						Anesthesiology
						Anesthesia Assistant
						MDA
						Anesthesiologist
						Radiology
						Radiology Technician
						Radiologist
						Environmental
						Ambulance/EMS
						EMT
						Paramedic
						ER
						Intensive Care
						Post-op
						CCU
						Cardiac
						Recovery
						Visiting Hours
						Limited
						Generous
						Restricted
						Discretion
						Step-Down
						Telemetry
						Cath Lab
						Operating Room (OR)
						Surgery
						Emergently
						Emergent
						Discharge
						Home
						Rehab
						Post op day

Appendix

Complications Following an Emergent CABG

Working a staff nurse in a busy cardiac intensive care unit provides ample opportunity for excitement and learning. Recovering post-op cardiac surgery patients can be one of the most challenging of patient types, and is complicated even more when the surgery is performed emergently. One such case provided as much challenge and excitement as a nurse could bear, and marked a long and tempestuous road toward recovery for the patient.

Perry presented to the ER on a Sunday afternoon. He had just laid down for a nap after having finished lunch. He suddenly felt the characteristic chest pain of an MI, which was crushing pressure radiating down his right arm. PerryÕs wife immediately called EMS who brought him to the ER. Upon arrival, PerryÕs EKG showed significant ST-segment elevation with frequent ectopic beats and low blood pressure. His pain and other symptoms were not relieved with IV and SL nitroglycerine and the blood pressure continued to fall. The patient was then started on heparin and dopamine and sent to the cath lab for emergent coronary angiography. The heart cath revealed severe triple vessel disease requiring emergent CABG. After placement of invasive lines to include Swan Ganz, arterial line, and IABP, the patient was transferred to the OR. After 5 hours of uncomplicated surgery where the patient received 6 bypasses, the patient was transferred to the CICU for recovery. Perry recovered from the surgery and anesthesia over the next 6 hours. His vital signs and hemodynamics remained stable such that he was extubated and quickly weaned to a 5 liter cannula. The IABP was discontinued the following evening and the patient continued to progress quickly. On the am of the 2^nd post op day, the patient was transferred to the stepdown pending discharge.

Three days after his discharge from the CICU, Perry developed a tachyarrhythmia coupled with hypotension and fever. Surgical infection was suspected as the patientsÕ lungs and CXR were clear, however it was noted that the patientsÕ abdomen was large, firm, and tender. An abdominal radiograph revealed inconclusive findings suggestive of a possible paralytic ileus or possible obstruction. The treatment included stool softeners, enemas, and activity. The patient stated he was week but this was attributed to his recent surgery and subsequent bedrest. Following a night of rest, the patient was encouraged to get up to sit at the bedside.

Perry felt strong enough to go to the commode and was assisted to walk the 10 feet to the commode. After sitting on the commode for approximately 5 minutes, the patient called for help stating he could not hold himself up any longer. He agreed that moving to the chair might require less exertion than going back to bed, so he was transferred to the chair. As soon as the patient sat in the chair, he became unresponsive, his pupils dilated, breathing became agonal, and his blood pressure declined to 50/X. Help was obtained to return the patient to bed and the house staff was called emergently to see the patient. Fluids were administered along with starting of levophed to support the BP. Chest compressions were performed briefly and respirations were assisted using an ambu bag. The patient was re-intubated by an anesthesiologist and placed on ventilator support. A subsequent CT of the abdomen revealed an infracted segment of the bowel which was leaking bowel contents into the peritoneum. The patient and his family were advised of the events and encouraged to allow surgical repair of the bowel to save the patients life. The patient underwent a right hemicolectomy with ileostomy, was placed on numerous antibiotics, and returned back to the CICU where he recovered over the next four days, was extubated, and eventually discharged to the stepdown in preparation to go home. The physicians plan to reverse the ileostomy after the patient has had time to recover from the two previous surgeries and the patient continues to recover.