Cardiovascular Care Plans
PART I: Medical-Surgical Nursing
continued
ASSESSMENT/INTERVENTIONS RATIONALES
Administer fluids and medications as prescribed and according to the type of shock, the patient’s clinical situation, and hemodynamic interventions. See the following table.
Interventions are determined by the clinical presentation and severity of the shock state. Patients are transferred to ICU for invasive hemodynamic monitoring with pulmonary artery catheter and use of vasoactive intravenous (IV) drips to improve tissue perfusion.
Avoid rapid delivery of colloidal fluids in the treatment of hypovolemic shock.
Very rapid infusion of colloidal fluids may precipitate pulmonary edema.
Cardiogenic Shock
- Vascular support To reduce cardiac workload.
- Intraaortic balloon counterpulsation To augment perfusion pressures.
- Ventricular assist devices To bypass or assist the ventricles, lowering myocardial oxygen requirements, reducing cardiac stress, and permitting cardiac muscle rest.
- Fluid administration or diuretics To optimize blood volume. Fluids may be limited to prevent overload (the heart is not able to handle the volume already in the intravascular space), yet dehydration must be avoided. Decreasing preload (fluids) may be the treatment of choice to take the workload off the heart. An indwelling urinary catheter should be inserted for accurate output measurement.
- Inotropes (e.g., dopamine) To increase cardiac contractility.
- Antidysrhythmics To control rapid, irregular heart rate.
- Morphine To reduce severe chest pain and reduce preload and afterload.
- Vasodilators (e.g., nitroprusside, nitroglycerin) To increase peripheral perfusion and reduce afterload vasoconstriction caused by vasopressors.
- Osmotic diuretics To increase renal blood flow.
- O2 support To increase oxygen availability to the tissues.
Anaphylactic Shock
- Epinephrine (0.5 mL, 1 : 1000 in 10 mL saline): To promote vasoconstriction and decrease the allergic response by counteracting vasodilation caused by histamine release.
- Bronchodilators To relieve bronchospasm.
- Antihistamines To prevent relapse and relieve urticaria.
- Hydrocortisone For its antiinflammatory effects.
- Vasopressors May be necessary for reversing shock state.
- O2 and airway support To increase oxygen availability to the tissues.
- Albumin Colloidal infusion to increase vascular volume.
- Ringer’s solution Isotonic solution to replace intravascular fluid, electrolytes, and ions. In shock states, fluid leaves the intravascular spaces.
Septic Shock
- Antibiotic therapy Initial therapy is broad spectrum. Once the causative organism is
identified, specific antibiotic therapy can be initiated.
- Fluid administration To maintain adequate vascular volume.
- Vasoactive agents (e.g., norepinephrine, dopamine) To reverse vasodilation and maintain perfusion.
- Positive inotropic medications (e.g., dopamine) To augment cardiac contractility.
PART I: Medical-Surgical Nursing
Hypovolemic Shock
- Control of volume loss Essential to decrease life-threatening complications and mortality.
- Blood transfusion To increase O2 delivery at the tissue level when more than 2 L of blood
has been lost. Often a combination of packed red blood cells (RBCs) and a crystalloid solution is administered.
- Albumin Colloidal infusion to increase vascular volume.
- Ringer’s solution Isotonic solution to replace fluids, electrolytes, and ions lost with
bleeding.
Nursing Diagnosis:
Impaired Gas Exchange
related to altered oxygen supply occurring with decreased respiratory muscle function
Desired Outcome:
Within 1-2 hr of intervention, the patient has adequate gas exchange as evidenced by Sa
O2greater than 92%; Pa
O2at least 80 mm Hg; Pa
CO245 mm Hg or less; pH at or near 7.35; presence of eupnea; and orientation to person, place, and time.
ASSESSMENT/INTERVENTIONS RATIONALES
Monitor ABG results. Report significant findings. The presence of hypoxemia (decreased PaO2), hypercapnia (increased PaCO2), acidosis (decreased pH, increased PaCO2, and increased lactate levels) are signs of decreased gas exchange.
Monitor SaO2. Report significant findings. Readings of 92% or less are indicators of decreased oxygenation, and oxygen therapy likely will be required.
Assess respirations q30min; note and report presence of tachypnea or dyspnea.
Fast or labored breaths may signal respiratory distress and possibly respiratory failure. Tachypnea and dyspnea also may be signs of pain, anxiety, or infection and should be evaluated accordingly.
Assess for mental status changes, restlessness, irritability, and confusion.
Often these are symptoms of hypoxia.
Report significant findings. Supplemental oxygen or other respiratory interventions likely will be required.
Teach the patient to breathe slowly and deeply in through the nose and out through the mouth.
These actions slow the respiratory cycle for better alveolar gas exchange.
Ensure the patient has a patent airway; suction secretions as needed. This intervention promotes gas exchange.
Administer O2 as prescribed; deliver O2 with humidity. These interventions increase oxygen supply and help prevent its convective drying effects on oral and nasal mucosa.
ADDITIONAL NURSING DIAGNOSES/PROBLEMS:
“Psychosocial Support” p. 72
“Psychosocial Support for the Patient’s Family and Significant Other”
p. 84
PATIENT-FAMILY TEACHING AND DISCHARGE PLANNING
For interventions, see discussion of the patient’s primary
diagnosis.
149
Cardiac Surgery 18
OVERVIEW/PATHOPHYSIOLOGY
Surgical intervention may be necessary to treat acquired or congenital heart disease. Coronary artery bypass grafting
(CABG) is performed to treat blocked coronary arteries. Aportion of the saphenous vein, internal mammary artery, gas-troepiploic artery, or radial artery is excised and anastomosed to coronary arteries, revascularizing the affected myocardium.
Valve repair or replacement is performed for patients with
val-vular stenosis or valval-vular incompetence of the mitral, tricus-pid, pulmonary, or aortic valve. Aortic surgery may be done to remove or repair an aortic aneurysm. Other types of cardiac surgeries are performed to correct heart defects that are either acquired or congenital, such as ventricular aneurysm, ven-tricular or atrial septal defects, transposition of the great vessels, and tetralogy of Fallot. Heart transplantation may be considered for some patients diagnosed with end-stage cardiac disease; however, the national shortage of acceptable donor organs remains an obstacle. Some patients waiting for heart transplants may have a ventricular assist device placed to serve as a bridge until transplant. Combined heart-lung
transplantation is performed for patients with end-stage disease
affecting both organs.
Many patients undergoing cardiac surgery may have tem-porary epicardial pacing wires placed. These wires are placed on the heart at the time of surgery and pulled through the chest wall where they can be attached to a temporary pace-maker. They are used for temporary pacing postoperatively if needed. When no longer needed, they may be removed by nurses or other health care providers who have demonstrated technical proficiency.
HEALTH CARE SETTING
When the surgery is elective, patients are often admitted to the hospital on the day of surgery. However, many patients undergoing cardiac surgery may be in an emergent or urgent situation and may be directly admitted from an emergency room, clinic, or medical office.
During the perioperative period, many patients may need to be in a cardiac or intensive care unit (CCU/ICU) for monitoring and stabilization. When stable they may be trans-ferred to a cardiac unit.
Nursing Diagnosis for Preoperative Patients:
Deficient Knowledge
related to unfamiliarity with the diagnosis, surgical procedure, preoperative routine, and postoperative course
Desired Outcome:
Before surgery, the patient verbalizes knowledge about the diagnosis, surgi-cal procedure, and preoperative and postoperative regimens.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess the patient’s health care literacy (language, reading, comprehension). Assess culture and culturally specific information needs.
This assessment helps ensure that information is selected and presented in a manner that is culturally and educationally appropriate.
Assess the patient’s level of knowledge about the diagnosis and surgical procedure, and provide information as necessary. Encourage questions, and allow time for verbalization of concerns and fears.
Knowledge level will vary from patient to patient. Some patients find detailed explanations helpful; others prefer brief and simple explanations. The amount of information given depends on learning needs and should be individualized.
When appropriate, provide orientation to the ICU and equipment that will be used postoperatively.
Familiarity with the unit and equipment optimally will promote understanding and minimize stress.
PART I: Medical-Surgical Nursing
Provide instructions for and demonstrate deep breathing and coughing techniques; ask the patient to give a return demonstration.
Deep breathing and coughing are essential postoperative techniques that reinflate the lungs after heart-lung bypass and help prevent atelectasis and pneumonia.
Reassure the patient that postoperative pain will be managed with medication. Explain the types of medication administration available—i.e., epidural, patient-controlled analgesia (PCA), intermittent intravenous (IV), and by mouth (PO).
This information may aid in reducing anxiety about postoperative pain and increase understanding of the types of pain medications.
Advise the patient that in the immediate postoperative period, speaking will be impossible but that other means of communication (e.g., nodding, writing) will be available.
An endotracheal tube that will assist with breathing will prevent speech.
Knowledge that alternative methods will be employed will reassure and help prepare patients.
Review and demonstrate sternal precautions. Sternal precautions include how to get in and out of the bed and chair without using upper extremities; not lifting, pushing, or pulling more than 5-10 lb with each upper extremity for a period of 4-6 wk; and not driving a car for the same period of time.
Nursing Diagnosis:
Activity Intolerance
related to generalized weakness and bedrest following cardiac surgery
Desired Outcome:
By a minimum of 24 hr before hospital discharge, the patient rates per-ceived exertion at 3 or less on a 0-10 scale and exhibits cardiac tolerance to activity after cardiac surgery as evidenced by heart rate (HR) 110 bpm or less, systolic blood pressure (SBP) within 20 mm Hg of resting SBP, and respiratory rate (RR) 20 breaths/min or less with normal depth and pattern (eupnea).
ASSESSMENT/INTERVENTIONS RATIONALES
Assess vital signs at frequent intervals, and be alert to any changes. Notify the health care provider of significant findings, including a blood pressure (BP) change greater than 20 mm Hg.
Hypotension, tachycardia, crackles (rales), tachypnea, and diminished amplitude of peripheral pulses are signs of cardiac complications and should be reported promptly for timely intervention.
Ask the patient to rate perceived exertion (RPE) during activity, and monitor for evidence of activity intolerance. Notify the health care provider of significant findings.
An RPE greater than 3, along with cool, diaphoretic skin, is a signal to stop the activity and notify the health care provider. See Chapter 4, “Prolonged Bedrest,” Risk for Activity Intolerance, p. 62, for a discussion of RPE.
Facilitate coordination of health care providers to provide rest periods between care activities and thus decrease cardiac workload.
Uninterrupted rest of at least 90 min helps decrease cardiac workload. An increased cardiac workload is likely if too many activities are performed without concomitant rest.
Assist with exercises, depending on tolerance and prescribed activity limitations. As prescribed, initiate physical therapy (PT) and/or cardiac rehabilitation.
Monitored exercise increases activity tolerance.
See Chapter 4, “Prolonged Bedrest,” Risk for Activity Intolerance, p. 61, and Risk for Disuse Syndrome, p. 63, for a discussion of in-bed exercises.