Display hemodynamic stability, such as stable blood pressure, cardiac output.
Report and display decreased episodes of angina and dysrhythmias.
Demonstrate an increase in activity tolerance.
Participate in activities that maximize and enhance cardiac function.
NOC
ACTIONS/INTERVENTIONS RATIONALE
Hemodynamic Regulation Independent
Monitor and document trends in heart rate and BP, especially noting hypertension. Be aware of specific systolic and dias- tolic limits defined for client.
Monitor and document cardiac dysrhythmias.
Observe client response to dysrhythmias, such as drop in BP, chest pain, and dyspnea.
Observe for bleeding from incisions and chest tube (if in place).
Observe for changes in usual mental status, orientation, and body movement or reflexes, such as onset of confusion, dis- orientation, restlessness, reduced response to stimuli, and stupor.
Record skin temperature and color and quality and equality of peripheral pulses.
Measure and document intake and output (I&O) and calculate fluid balance.
Schedule uninterrupted rest and sleep periods. Assist with self- care activities as needed.
NIC
Tachycardia is a common response to discomfort, inadequate blood or fluid replacement, and the stress of surgery. How- ever, sustained tachycardia increases cardiac workload and can decrease effective cardiac output. Hypotension may re- sult from fluid deficit, dysrhythmias, heart failure, and shock. Hypertension can occur (fluid excess or preexisting condition), placing stress on suture lines of new grafts and changing blood flow or pressure within heart chambers and across valves, with increased risk for various complications.
Hypothermia, inhaled anesthetics, electrolyte and metabolic disturbances, manual manipulation of the heart, and myo - cardial ischemia may be factors in postoperative dysrhyth- mias. The incidence of atrial fibrillation ranges from 10% to 65% depending on many factors, including preoperative history and medications and type of surgery performed (Kern, 2004). Decreased cardiac output and hemodynamic compromise that occur with dysrhythmias require prompt intervention.
Helps identify bleeding complications that can reduce circulat- ing volume, organ perfusion, and cardiac function.
May indicate decreased cerebral blood flow or systemic oxy- genation as a result of diminished cardiac output—sus- tained or severe dysrhythmias, low BP, heart failure, or thromboembolic phenomena, including perioperative stroke.
Warm, pink skin and strong, equal pulses are general indicators of adequate cardiac output.
Useful in determining fluid needs or identifying fluid excesses, which can compromise cardiac output and oxygen consumption.
Prevents fatigue or exhaustion and excessive cardiovascular stress.
CHAPTER 4CARDIOVASCULAR—CARDIAC SURGERY
ACTIONS/INTERVENTIONS
(continued)RATIONALE
(continued)Monitor graded activity program. Note client response; vital signs before, during, and after activity; and development of dysrhythmias.
Evaluate presence and degree of anxiety or emotional duress.
Encourage the use of relaxation techniques such as deep breathing and diversional activities.
Inspect for JVD, peripheral or dependent edema, congestion in lungs, shortness of breath, and change in mental status.
Investigate reports of angina or severe chest pain accompanied by restlessness, diaphoresis, and ECG changes.
Investigate and report profound hypotension and unrespon- siveness to fluid challenge, tachycardia, distant heart sounds, and stupor or coma.
Collaborative Review serial ECGs.
Measure cardiac output and other functional parameters, as indicated.
Monitor Hgb, Hct, and coagulation studies, such as activated prothrombin time (aPTT), international normalized ratio (INR), activated clotting time (ACT), and platelet count.
Monitor results of thromboelastography (TEG), as indicated.
Administer intravenous (IV) fluids or blood products as needed.
Administer supplemental oxygen as appropriate.
Administer electrolytes and medications, as indicated, such as potassium, antidysrhythmics, digoxin preparations, diuretics, and anticoagulants.
Maintain surgically placed pacing wires (atrial or ventricular) and initiate pacing if indicated.
Regular exercise stimulates circulation and promotes feeling of well-being. Progression of activity depends on cardiac tolerance.
Excessive or escalating emotional reactions can negatively af- fect vital signs and systemic vascular resistance, eventually affecting cardiac function.
May be indicative of acute or chronic heart failure.
Although not a common complication of CABG, perioperative or postoperative MI can occur.
Development of cardiac tamponade can rapidly progress to car- diac arrest because of the heart’s inability to fill adequately for effective cardiac output. Note: This is a relatively rare, life-threatening complication that usually occurs in the im- mediate postoperative period but can occur later in the re- covery phase.
Most frequently done to follow the progress in normalization of electrical conduction patterns and ventricular function after surgery or to identify complications such as peri - operative MI.
Useful in evaluating response to therapeutic interventions and identifying need for more aggressive or emergency care.
Help to identify bleeding or clotting problems associated with the surgery. Note: Diverting the client’s blood through the CPB machine activates the clotting cascade and decreases the number (as well as the function) of platelets. Hemodilu- tion occurs when the client’s blood mixes with the crystal- loid solution used to prime the CPB machine. Because blood is being diluted, the Hct drops, as does the concentration of coagulation factors, fibrinogen, and platelets. In addition, the use of hypothermia during surgery to decrease tissue oxygen requirements slows down the process of clotting and decreases platelet function.
TEG is a point-of-care test that can rapidly identify whether the client has a normal hemostasis or is bleeding and whether it is due to surgery, coagulopathy, or residual anticoagulation therapy. Results will identify the specific therapy to treat it, whether client needs fresh frozen plasma (FFP), platelets, antifibrinolytic drugs, or thrombolytic drugs (Lab Tests Online, 2012; Sorensen et al, 2006).
Clients who have surgery on CPB equipment are more likely to bleed excessively than those who have off-bypass car- diac surgery. RBC replacement is often indicated to re- store and maintain adequate circulating volume and enhance oxygen-carrying capacity. IV fluids may be dis- continued before discharge from the ICU or may remain in place for fluid replacement and emergency cardiac medications.
Promotes maximal oxygenation to reduce cardiac workload and aid in resolving myocardial irritability and dysrhythmias.
Client needs are variable, depending on type of surgery, client’s response to surgical intervention, and preexisting condi- tions, such as general health, age, and type of heart disease.
Electrolytes, antidysrhythmics, and other heart medications may be required on a short-term or long-term basis to maxi- mize cardiac contractility and output.
May be required to support cardiac output in presence of con- duction disturbances (severe dysrhythmias) that compro- mise cardiac function.
N U R S I N G D I A G N O S I S : acute Pain
May Be Related To
Injuring physical agents—surgical incisions, tissue inflammation, edema formation, intraoperative nerve trauma Possibly Evidenced By
Verbal/coded reports of pain Guarding behavior
Expressive behaviors—restlessness, irritability Changes in heart rate, blood pressure, respiratory rate
Desired Outcomes/Evaluation Criteria—Client Will
Pain LevelVerbalize relief or absence of pain.
Demonstrate relaxed body posture and ability to rest and sleep appropriately.
Pain Control
Differentiate surgical discomfort from angina or preoperative heart pain.
NOC
NOC
ACTIONS/INTERVENTIONS RATIONALE
Pain Management Independent
Note type and location of incision(s).
Encourage client to report type, location, and intensity of pain, rating it on a scale. Note associated symptoms. Ascertain how this compares with preoperative chest pain.
Observe for anxiety, irritability, crying, restlessness, and sleep disturbances.
Monitor vital signs.
Identify and promote position of comfort, using adjuncts as necessary.
Provide comfort measures, such as back rubs and position changes, assist with self-care activities, and encourage diversional activities, as indicated.
Schedule care activities to balance with adequate periods of sleep and rest.
Identify and encourage use of behaviors such as guided imagery, distractions, visualizations, and deep breathing.
Tell client that it is acceptable, even preferable, to request analgesics as soon as discomfort becomes noticeable.
Medicate before procedures and activities, as indicated.
Investigate reports of pain in unusual areas, for instance, calf of leg or abdomen—or vague complaints of discomfort, espe- cially when accompanied by changes in mentation, vital signs, and respiratory rate.
Note reports of pain or numbness in ulnar area (fourth and fifth digits) of the hand, often accompanied by pain and discom- fort of the arms and shoulders. Tell client that the problem usually resolves with time.
NIC
Newer procedures, such as MIDCAB, require smaller chest and leg incisions, with less significant pain. Many CABG clients do not experience severe discomfort in chest incision and may complain more often of donor site incision discomfort.
Severe pain in either area should be investigated further for possible complications.
Pain is perceived, manifested, and tolerated individually. It is important for client to differentiate incisional pain from other types of chest pain, such as angina or discomfort from chest tubes.
These nonverbal cues may indicate the presence or degree of pain being experienced.
Heart rate usually increases with acute pain, although a brady- cardic response can occur in a severely diseased heart. BP may be elevated slightly with incisional discomfort but may be decreased or unstable if chest pain is severe or myocar- dial damage is occurring.
Pillows or blanket rolls are useful in supporting extremities, maintaining body alignment, and splinting incisions to re- duce muscle tension and promote comfort.
May promote relaxation, redirect attention, and reduce anal- gesic dosage or frequency.
Rest and sleep are vital for cardiac healing (balance between oxygen demand and consumption) and can enhance coping with stress and discomfort.
Relaxation techniques aid in management of stress, promote sense of well-being, may reduce analgesic needs, and promote healing.
Presence of pain causes muscle tension, which can impair circulation, slow healing process, and intensify pain.
Client participation in respiratory treatments, ambulation, and procedures, such as removal of chest tubes, pacemaker wires, and sutures, are facilitated by maximum analgesic blood level.
May be an early manifestation of developing complication, such as thrombophlebitis, infection, and gastrointestinal dysfunction.
Indicative of a stretch injury of the brachial plexus as a result of the position of the arms during surgery. No specific treat- ment is currently useful.
CHAPTER 4CARDIOVASCULAR—CARDIAC SURGERY
ACTIONS/INTERVENTIONS
(continued)RATIONALE
(continued)Collaborative
Administer analgesics medications—(e.g., opioids, nonsteroidal anti-inflammatory drugs [NSAIDs]) by appropriate route (e.g., IV, patch, by mouth) as indicated
Provides for control of pain and inflammation and reduces muscle tension, which improves client comfort and pro- motes healing. Note: IV narcotics will be used during the immediate postoperative period, while client is intubated.
Oral narcotics will most likely still be required for some time after extubation. Narcotic-induced respiratory depression is a risk during this time, requiring vigilant monitoring of client’s respiratory status.