Date of Conferral

6-12-2025

Degree

Doctor of Nursing Practice (DNP)

School

Nursing

Advisor

Patricia Schweickert

Abstract

Walden University College of Nursing This is to certify that the doctoral study by Marjorie B. Yumul has been found to be complete and satisfactory in all respects, and that any and all revisions required by the review committee have been made. Review Committee Dr. Patricia Schweickert, Committee Chairperson, Nursing Faculty Dr. Diane Whitehead, Committee Member, Nursing Faculty Chief Academic Officer and Provost Sue Subocz, Ph.D. Walden University 2025 Executive Summary: Clinical Practice Guideline Preoperative Clinical Practice Guidelines for Patients Undergoing Coronary Artery Bypass Graft Surgery by Marjorie B. Yumul MS, University of the Philippines Manila, 2003 BS, La Concordia, 1995 Executive Summary Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University May 2025 Summary This doctoral project was a clinical practice guideline (CPG) focused on the development of a preoperative practice guideline for patients undergoing coronary artery bypass graft surgery (CABG). The lack of systematic evidence based organization of preoperative nursing care creates confusion in nursing roles and responsibilities. It is important to standardize care based on evidence to ensure patient readiness and prevent care delays. Therefore, the purpose of this project was to create a preoperative CPG for patients undergoing CABG. Specifically, this project was conducted to answer the project question: Does the evidence support the development of a CPG for preoperative CABG management that was validated by the expert panel using the appraisal of guideline for research and evaluation (AGREE) II tool and was approved for use in the clinical practice setting by end users? To support this project, I used the John Hopkins evidence-based practice model for evidence appraisal and synthesis. Twenty of the 40 related articles found from research databases support this project. The four members of the expert panel used the AGREE II instrument to evaluate this CPG. Their responses to each of the six domains were tabulated and analyzed, showing results between 92% and 95%. Additionally, a 96.4% overall score was obtained and reflected their recommendations of unanimous approval by end users in practice to help standardize evidence for care for preoperative nursing practice to promote improved patient care outcomes. The holistic approach of the preoperative CPG encourages positive social changes with equality among patients regardless of their race, sexual orientation, status of living, educational attainment, age or cultural diversity. Background The identified practice problem on the lack of systematic organization of pre-operative nursing care among patients undergoing CABG among floor nurses creates confusion in their roles and responsibilities, supporting the need for practice change intended to help bridge the gap in practice in the acute care setting. Coronary heart disease is considered one of the world’s leading causes of morbidity, disability, restricted quality of life, and mortality (Salzsmann et al, 2022). CABG has been established as the gold standard of treatment for patients with severe coronary heart disease, and it aims to reduce disability, physical symptoms, and morbidity and improve quality of life (Salzsmann et al, 2022). For most patients, the risks of surgery are low; however, high-risk patients have an increased risk of suffering from postoperative comorbidities and death, and therefore, there is a need to improve the identification of high-risk patients and clinical outcomes as well as reduce health care costs (de Waard, 2021). Many times, nurses are responsible for the patient’s physical, emotional, and psychological preoperative preparation for the upcoming surgery. A review study on the psychological preparation of patients undergoing surgery showed that many of these interventions informed the surgical procedure and the recovery process (Zhang, 2021). The care provided had the objective of qualifying the patient for surgery, though they may be experiencing anxiety symptoms, such as increased heart rate or blood pressure, sweating, confusion, and tremors, which occur more often when the patient is exposed to unknown situations. The nursing interventions effectively improved the quality of nursing care of post-CABG patients, which improved the patients’ satisfaction (Sherrin et al., 2017). This showed how systematized and standardized preoperative care resulted in a decrease in the undesirable postoperative patient outcomes. Additional evidence supported that nursing CPGs are effective in improving the quality of nursing care of post-CABG patients, which in turn also improved the patients’ satisfaction (Ciapponi et al., 2020). Therefore, I developed a preoperative CPG among patients undergoing a CABG (see Appendix). Specifically, I conducted this doctoral project to answer the following question: Does the evidence support the development of a CPG for preoperative CABG management that is validated by the expert panel using the AGREE II tool and is approved for use in the clinical practice setting by end users of the guideline? The purpose of this doctoral project was to create preoperative CPGs for patients undergoing CABG. This doctoral project was supported by the following levels of evidence, including overall quality ratings and a summary of findings. High-quality level I evidence supported the development of this CPG for preoperative CABG management. Randomized clinical trials provided high-quality evidence that the pre-surgery optimization of patient’s expectations improves the outcome of heart surgery using psychological interventions, like EXPECT, PSY HEART II trial, and nursing guidelines on cardiac surgery (Salzsmann, et al 2022). Most systematic reviews from the 10 randomized clinical trials support this project related to the quality of CPGs for preoperative care using the AGREE II instrument. These preoperative clinical guidelines have a great impact on postoperative complications, with a reduction of at least 63% total cost for preoperative tests, and preoperative evaluation for risks of mortality and morbidity after surgery (Ferrando, 2005). Other related evidence, such as three methodological reviews of high-quality related evidence, addressed the importance of perioperative care in the aortic valve surgery that has structured elements around the enhanced recovery after surgery. McGuinigle (2022) described enhanced recovery after surgery as delivering high-quality perioperative care and accelerating recovery, explaining that it appears well suited to address the needs of patients undergoing open aortic operations. In addition, an explanatory, mixed-method study showed that most CPG in the preoperative assessment of those undergoing elective surgery focused on preoperative fasting, cardiac assessment, and routine preoperative tests (Kotfis, 2020). Level II related studies have shown that caring behavior, good communication, counseling services, spiritual services, and effective education from nurses and doctors enable better patient control of self-care, psychological stress, and hospitalization stress (Iryanidar, 2023). Lastly, a quasi–experimental study showed that nursing process based on the CPGs was effective in improving the quality of nursing care of post-CABG patients, which improves patients’ satisfaction that starts in good preoperative care (Jhony, 2017). Jhony (2017) further described that CABG is one of the most high-risk and high-cost surgery performed all over the world. Postoperative complications prolong the length of hospitalization, and CPGs are relatively new quality improvement tools that are developed for maintaining quality, minimizing costs, and improving outcomes. Clinical Practice Guideline Development This CPG project was evaluated by an expert panel of four members who I carefully selected based on their field of clinical expertise supporting the doctoral project, level of education, and years of related experience. Two members of the expert panel hold master’s degree in nursing and have worked as nurse educators in the medical surgical/telemetry unit and in the preoperative holding area and operating room. They have been nursing educators in the hospital for more than 5–10 years. Their expertise and recommendations helped with the development of this project. Two additional members of the expert panel hold doctorate degrees in nursing practice: one is a cardiovascular nurse specialist, and the other is a medical/surgical/stepdown/telemetry clinical nurse specialist. Both contributed knowledge on the content and development of the CPG through their practice expertise. I used the AGREE II Instrument in this project to measure the quality and appropriateness of the CPG, including addressing the issue of variability in guideline quality and assessing the methodological rigor and transparency of the guideline’s development. This instrument consists of 23 key items organized within six domains followed by two global rating items. Each domain captures a unique dimension of guideline quality. Included in the six domains are: The scope and purpose for domain 1, which is concerned with the overall aim of the guidelines, the specific health questions, and the target population (i.e., Items 1–3). A focus on the extent to which the guideline was developed by the appropriate stakeholders and represents the views of its intended users (i.e., Items 4–6) was in domain 2 for the stakeholder involvement. When it comes to the rigor of development, domain 3 relates to the process used to gather and synthesize the evidence, the methods to formulate the recommendations, and to update them (i.e., Items 7–14). The clarity of the presentation deals with the language, structure, and format of the guidelines (i.e., Items 15–17) were in domain 4 of the tool. Assessing the applicability of the project, domain 5 involves the barriers and facilitators in implementation strategies to improve uptake and resource implications of applying the guideline (i.e., Items 18–21) Lastly, domain 6 comprises the editorial independence and is concerned with the formulation of recommendations not being unduly biased by competing interests (i.e., Items 22–23). The overall assessment includes the rating of the overall quality of the guideline and whether it would be recommended for use in practice. All AGREE II items are rated on the following 7-point scale. The score of 1 (Strongly Disagree) means no information is relevant to the AGREE II item or the concept is very poorly reported. A score of 7 (Strongly Agree) should be given if the quality of reporting is exceptional and where the full criteria and considerations articulated in the user’s manual have been met. Scores between 2 and 6 are assigned when the reporting of the AGREE II item does not meet the full criteria or considerations. Domain scores are calculated by summing up all the scores of the individual items in a domain and by scaling the total as a percentage of the maximum possible score for that domain. Upon completing the 23 items, AGREE II users provided two overall guideline assessments. The comprehensive evaluation required the user to make a judgment as to the quality of the guideline, considering the criteria considered in the assessment process. The user was also asked whether they would recommend using the guideline. Results In this section, I discuss the AGREE II results from the expert panel review with the 23 domains using the Likert scale. Figure 1 reflects the scores from the six domains. Each of the domains resulted with a quality rating from the expert panel. Specifically, Domains 1 and 2 obtained the same rating of 94%, which reflects high-quality clarity of the scope and purpose as written and presented in the guideline. Additionally, the stakeholders’ involvement was clear with defined roles and identification of barriers before the actual implementation. For Domain 3, which focuses on the rigor of development, most of the clinical experts agreed that I employed a systematic method to search for evidence for the preoperative CPG with the use of PRISMA diagram for the selection of related evidence resources from MEDLINE, CINAHL, and Cochrane Review databases to support the doctor project. The selection of the related evidence following the inclusion and exclusion criteria served the purpose and was clearly described. For better understanding on the part of the expert panel, the clarity of presentation was important. The Domain 4 results showed a score of 98.6%, reflected the in-person delivery of the project, and provided more information and clarity with an opportunity to have an actual interaction addressing their questions about the project and receiving their feedback and recommendations. One recommendation was to add medication, such as Enoxaparin, Clopidogrel, heparin, or semaglutide. A dentist consultation should be made with those patients with valvular defect or conditions needing valvular surgery. In terms of the applicability of the project, which is Domain 5, most of the expert panel agreed that the facilitators and barriers before its application were addressed in the guideline with a score of 94.7%. The discussions on how barriers will be prevented and handled were raised with subsequently agreed upon recommendations. The last domain, editorial independence, scored 95.8% indicating that the CPG was not biased and/or did not have any competing interests. The overall guideline assessment showed that the CPG reflected high quality and was recommended for use in the practice setting by end users with an overall quality rate of 96.4%. Therefore, this CPG was recommended for use by end users, with some recommendations. This project has great potential for positive social change when adopted in the project site organization because it aims to standardize evidence-based preoperative nursing care practice. Since there is no CPG preoperatively, this project can be utilized in the organization to standardize evidence-based practice. This doctoral project was limited to standardizing preoperative care for patients undergoing CABG. The CPG guideline supports the idea that improving the quality of nursing care of post-CABG patients and patients’ satisfaction starts with standardized evidence-based preoperative care. This is mostly beneficial to uncomplicated and scheduled cases for CABG. Thus, once adopted for use in the project site organization, the project will be submitted to the regional office that approves and verifies any projects and policies created or revised because it aims to standardize the preoperative nursing practice across different branches of the organization in all regions. Conclusions Preoperative CPGs provide a systematic approach in preparing patients for CABG. The creation of this guideline helps establish a patient care safety net before the procedure. Since there is no existing CPG for use by nurses, this CPG can be utilized in the project site organization to standardize evidence-based preoperative clinical nursing practice. It may also serve as a reference for related evidence-based projects or research. Enhancement of patient’s safety before any surgical procedures is a top priority through organized systematic preoperative care. The project created an awareness among the educators, unit leaders, and staff that the CPG is an important tool to develop quality nursing care and improve patient care outcomes. Further recommendations to consider include the usage of this preoperative CPG in the Medical/Surgical/Telemetry and Direct Observational Unit in the project site organization and at the regional level. This project can also be added to the CPG library of the organization and used as a reference for future development of the project. Nurses play a major role in the implementation of this project. Their readiness and barriers in adapting to evidence-based practice should be considered before its implementation. The effectiveness of this CPG project facilitating guideline dissemination and implementation requires validation by future empirical research. With an opportunity to transform professional practice, this project impacts positive social change because it applies to all nurses caring for cardiac patients needing CABG. This preoperative CPG provides an opportunity to standardize the care of those patients and fosters a positive social impact because it emphasizes the holistic care approach, which includes their family. This project follows Walden University’s positive social change as a deliberate process of creating and applying ideas, strategies, and actions to promote the worth, dignity, and development of individuals, communities, organizations, institutions, cultures, and societies. Thus, positive social change leads to the advancement of human and social conditions.   References Casale, J., Lurie,M., Khromava, M., & Silvay, G. (2020). Dental clearance and postoperative heart infections: Observations from a preoperative evaluation clinic for day-admission surgery. Journal of Perioperative Practice, 30(4), 97–101. https://doi.org/10.1177/1750458919853116 Ciapponi, A., Lopez, T. E., Sacha, V., & Bardach, A. (2020). The quality of clinical practice guidelines for preoperative care using the AGREE II instrument: A systematic review. Systematic Reviews, 9, 159. https://doi.org/10.1186/s13643-020-01404-8 De Waard, D., Fagan, A., Minnaar, C., & Horne, D. (2021). Management of patients after coronary artery bypass grafting surgery: A guide for primary care practitioners. CMAJ: Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne, 193(19), E689–E694. https://doi.org/10.1503/cmaj.191108 Ferrando, A., Ivaldi, C., Buttiglieri, A., Pagano, E., Bonetto, C., Arione, R., Scaglione, L., Gelormino, E., Merletti, F., & Ciccone, G. (2005, August). Guidelines for preoperative assessment: Impact on clinical practice and costs. Int J Qual Health Care, 17(4), 323-329. https://doi.org/10.1093/intqhc/mzi039 Iryanidar, I., & Irwan, M. (2023). Stress and coping mechanisms in patients undergoing CABG: An integrative review. Clinical Epidemiology and Global Health, 23,101388. https://doi.org/10.1016/j.cegh.2023.101388 Jacobsen, S., Douglas, A., Smith, C., Roberts, W., Ottwell, R., Oglesby, B., Yasler, C., Torgerson, T., Hartwell, M., & Vassar, M. (2021). Methodological quality of systematic reviews comprising clinical practice guidelines for cardiovascular risk assessment and management for noncardiac surgery. British Journal of Anaesthesia, 127(6), 905–916. https://doi.org/10.1016/j.bja.2021.08.016 Jhony, A., Moly, K., & Sreedevi, A., (2017). Effectiveness of nursing process based clinical practice guidelines on quality of nursing care among CABG patients. International Journal of Nursing Education, 9(2), 120-126. Kotfis, K., Jamioł-Milc, D., Skonieczna-Żydecka, K., Folwarski, M., & Stachowska, E. (2020, October 12). The effect of preoperative carbohydrate loading on clinical and biochemical outcomes after cardiac surgery: A systematic review and meta-analysis of randomized trials. Nutrients, 12(10), 3105. https://doi.org/10.3390/nu12103105 McGinigle, K. (2022). Perioperative care in open aortic vascular surgery: A consensus statement by the Enhanced Recovery After Surgery (ERAS) Society and Society for Vascular Surgery. Journal of Vascular Surgery, 75(6), 1796–1820. Salzmann, S., Laferton, J., Shedden-Mora, C., Horn, N., Gärtner, L., Schröder, L., Rau, J., Schade-Brittinger, C., Murmann, K., Rastan, A., Andrási, B., Böning, A., Salzmann-Djufri, M., Löwe, B., Brickwedel, J., Albus, C., Wahlers, T., Hamm, A., Hilker, L., & Rief, W. (2022). Pre-surgery optimization of patients’ expectations to improve outcome in heart surgery: Study protocol of the randomized controlled multi-center PSY-HEART-II trial. American Heart Journal, 254, 1–11. https://doi.org/10.1016/j.ahj.2022.07.008 Zhang, J., Li, C., Fu, C., Dong, J., Guo, W., & Zhu, Q. (2021). Effect of psychological intervention combined with family cooperation on the perioperative quality of life and psychological states of elderly patients with prostate cancer treated with compound kushen injection. Evidence-Based Complementary and Alternative Medicine, 2021, 1–7. https://doi.org/10.1155/2021/2971644   Appendix: Preoperative Clinical Practice Guideline 1. On admission: Patients diagnosed with multi-vessel diseases (MVD), CAD, valvular diseases (regurgitation, prolapse, stenosis etc.) or congenital heart diseases needing CABG will be prepared for the major surgery with the following procedures: 2. History and Physical Examination: The nurse will ensure that the cardiac team completes the history and physical examination (Attending physician and/or its medical residents and/or cardiovascular nurse practitioner). The Patient’s history about the following data: a. Past medical history (comorbidities – Diabetes, Hypertension, Cancer, hyperlipidemia, CVA, PVD, renal diseases, pulmonary diseases, etc.) Any complications from past surgeries, or any bleeding risk factors. b. Chief complaint (Chest pain, Shortness of breath, Jaw or Shoulder, and/or neck pain ). c. Social History (smoking, alcohol consumption, use of inappropriate drugs). d. Family History (Diabetes, Hypertension, Cancer, blood disorders, heart diseases, etc.) 3. The admission orders: Part of the admission orders following the history and physical examination include the following: a. Electrocardiogram b. Chest x-ray c. Carotid doppler d. Schedule for cardiac catheterization e. Vein mapping f. Blood works like complete blood count, blood chemistries, coagulation studies, cardiac enzymes, urinalysis/pregnancy test, and Plavix assay. 4. The Team: The medical and cardiovascular surgery team will be introduced to the patient and family. They will determine the risk identification for upcoming surgery based on the history, physical examination together with the laboratory and diagnostic results. The Healthcare Team involved in the care: The members of the healthcare team after introducing themselves to the patient and family will discuss their specific roles which are as follows: 1. The Primary Doctor is the attending physician who will see the patient's overall condition during hospitalization. 2. An Advanced Practice Provider (APP, NP, or PA) is the designated advanced practitioner who will check the patient’s progress and readiness for the upcoming surgery. 3. The Cardiac Surgeon and his team are responsible for doing the surgery together with the residents who are considered the first or second assistants during the actual operation. 4. An anesthesiologist is a medical doctor who will conduct the anesthesia and who will check the patient’s overall state of analgesia during the operation. The anesthesiologist will explain to the patient the type of anesthesia that will be given, methods of delivery, risks, and benefits under analgesia, monitoring and conduction, and side effects after the anesthesia wears off. 5. A Primary Nurse is a registered nurse assigned to the care of a patient who will undergo surgery and is responsible for the preparation of the patient for surgery. The primary nurse will do the preoperative checklist, release and carry out preoperative orders until the patient is confirmed with the OR schedule, and provide a handoff report to the OR nurse. 6. The dentist is responsible for doing a dental checkup for the patient before the surgery making sure the general oral condition of the patient is good. 7. Social Worker Consult: is involved in cases where the patient/family needs support, living will, Power of Attorney processing, and Jehovah’s Witness advance directive form as needed. Special consideration for those Jehovah’s Witness Patients, the Blood Management Plan should include the following: 7.1 Be sure that the patient/family/significant other has the hard copy of the Blood Management Plan for review, complete and signed. 7.2 The RN/SW encouraged the patient to talk to their Elders to assist with completing the form. 7.3. After the form is completed, the RN makes sure that it has been uploaded to the patient’s chart for documentation. 5. Scheduling: The scheduling of the surgery will be determined by the cardiac surgeon and their team in coordination with the Operating room scheduler / or the Department administrator/charge nurse. Once the schedule of the surgery was confirmed. The following preoperative orders will be written accordingly. Once the patient is eligible for coronary artery bypass graft surgery, the following will be obtained and witnessed: 1. Consent / Witnessed consent: 1.a. Obtained witness consent for surgery after the cardiac surgeon explained the procedure to the patient/family and by the anesthesiologist for the anesthesia witnessed consent by the assigned nurse. 1.b In case the patient is incapacitated to sign the consent, alternatives like the use of telephone consent will be done. 1.c. The Advance Practice Provider (APP, PA, or NP) will screen the patient’s chart, interview the patient, provide pre-op teachings, answer surgery-related questions, perform physical examination, and review the laboratory workup and other diagnostic results. 1.d. The APP documents daily preop progress notes in the patient’s chart regarding the progress and readiness for the surgery. 1.e. Throughout the preop process, the APP is the primary liaison between the surgeon, the primary care team, specialty consultants, & the RN assigned. 6. Preoperative Diagnostic Procedure Orders: The following are the anticipated preoperative procedure orders for the uncomplicated cases of patients undergoing Coronary Artery Bypass Surgery. The assigned nurse made sure that the following preoperative orders were done and relayed the abnormal or critical lab results to the medical/surgical team. It is the nurse’s responsibility to execute medical orders like Blood transfusions, iron infusion, replenishments for depleted electrolytes, and antibiotic prophylaxis. A. Laboratory Workup: 1. Blood typing and Screening (ABO and Indirect Coombs) 2. Coagulation Studies (INR, APTT, PT, Anti Xa,) 3. Complete Blood Count and Differential Studies 4. Blood Chemistries (Na, K, Cl, BUN, Crea, Magnesium, CO2, Phos, HgbA1C) 5. Liver Enzymes (T. Bilirubin, SGOT, SGPT, Albumin levels) 6. Plavix Assay – The P2y level must be >208 before a patient can proceed with the surgery. 7. Nasal Culture / or (Covid Swab test) 8 Urinalysis (Clean catch mid-stream urine specimen collection) if not done in the admission orders. 9. Pregnancy Test for Female patients who are of reproductive age (18-55 years old) if not done in admission orders. B. Invasive and Non-invasive diagnostic procedures, which include the 1. Chest X-ray (at least 1 view). This is usually part of the admission orders that will be used as part of the CABG evaluation by the Cardiovascular team. 2. Carotid Ultrasound- an important preoperative diagnostic procedure that the nurse will follow with the cardio technician to perform before CABG. No special preparation for this procedure but it will give significant results for any arterial occlusion or plaques that can impact heart surgery. 3. EKG (2x) On Admission and Before Surgery. The recent EKG results will be brought in by the primary nurse when transporting the patient and handed off to the operating room nurse at the time of CABG per organizational policy. 4. Transthoracic Echo – The nurse coordinates with the Echo technician for the execution of the procedure order. This will enable the cardiac team to evaluate the Ejection Fraction of the Left ventricles and, thus, also determine any stenosis and structural deformities if any, for this is a part of the cardiac evaluation before surgery. 5. Heart Catheterization - The medical team usually orders this procedure to determine any heart occlusions or stenosis. After the confirmation of the schedule with the Cath lab, the nurse prepares the patient and is expected to follow the preoperative orders such as: a. Witnessed consent for heart catheterization b. Have the patient shower as ordered c. Have another EKG in the morning before the procedure d. Perform CHG bath the night before heart catheterization e. Placed the patient’s NPO post-Midnight following the day of surgery f. Hair clipping 2x performed in the dayshift and at nighttime. The nurse should check the clipped area(s) to make sure it’s done appropriately g. Patients’ medication, such as Enoxaparin and heparin subcutaneously, will be held the night before the heart catheterization procedure. Other meds can be given like anti-hypertensive, anti-arrhythmic, aspirin, or antibiotics as ordered. Those patients on heparin drip or agatroban following the pharmacy protocol can be stopped and documented in the MAR (Medicine Administration Record) before the patient is transported to the Cath lab and or as ordered by the cardiologist. The primary nurse reports to the Cath lab nurse and transports the patient down to the Cath lab. 6. Other Miscellaneous Tests: These are the tests that the physician may order as deemed necessary. The Primary nurse will ensure that the following additional orders are completed and update the primary team about their execution. a. Dental Clearance (Only for Valvular Surgery). A tooth extraction may be performed by orthodontics to remove the damaged tooth that can cause tooth infection, thus may complicate the outcome of surgery. The primary nurse helps to coordinate the tooth extraction by coordinating the schedule at the OR and obtaining signed consent. b. Formal PFT (Bedside as performed by assigned Respiratory Therapist on the floor). This procedure, when ordered by the physician and the nurse, transported the patient to the pulmonary lab. c. Arterial Blood Gas (to be done by assigned R.T. on the floor) d. Computed Tomography Scan (CT scan) when further cardiac evaluation needs to be done. e. Magnetic Resonance Imaging Viability. This is done for further cardiac evaluation. The nurse made sure that it was done and made aware of the cardiac team. f. Cardiac CT scan – An optional procedure when the cardiac team assesses further studies to be done for further evaluation of the cardiac functions before surgery. The. The primary nurse would make sure it’s done and make the cardiac team aware. 7. Patient’s Physical Preparation Before Surgery Day: The Nurse physically prepares the patients following the preoperative guidelines, which include the following: a. Patient showers daily if possible: This is usually with the doctor’s order as part of the physical preparation. b. Trim Beards (Cannot have beard touching the chest) c. Use of Incentive Spirometer. The teachings should be done by the bedside nurse on its use and purposes. The demonstration and return demonstration of the device should be done by the nurse and patient. d. Referral for Physical Therapy ensures patients’ bed exercises or gradual mobility from room to hallway after cardiac surgery. Following the ERAS (Enhanced Recovery After Surgery) should be observed for faster healing and recovery. e. Bowel Elimination: If constipation is a problem, the primary team will address the bowel regimen. The patient will be placed nothing per orem post-midnight following the procedure. f. Hair clipping is done the day/or night before surgery by the RN and or Certified Nursing Assistants. g. Chlorhexidine Bath given 2x the night before and early morning before the actual surgery day. A topical Chlorhexidine wipes that contains Chlorhexidine wipes, containing the antiseptic chlorhexidine gluconate (CHG), are used to clean the skin, reduce the risk of infection, and are often used for pre-operative skin preparation. This CHG is a powerful antiseptic that kills or inhibits the growth of many types of bacteria, fungi, and viruses on the skin. In some cases, CHG wipes are used for daily baths, especially for individuals with compromised immune systems or those at high risk of infection. h. Nurse-Driven Functions: The primary nurse is in the best position to teach the following to patients undergoing CABG that includes: 1. Deep breathing exercises 2. Use of Incentive spirometry as mentioned above 3. Coughing ex...

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