M A Y R E P O R T (continued) M A Y E X H I B I T (continued)
Respiration
• Shortness of breath • Dyspnea
• Abnormal breath sounds, such as crackles
• Productive cough
Safety
Teaching/Learning
• Familial risk factors of diabetes, heart disease, hypertension, strokes
• Use of vari ous cardiovascular drugs
• Failure to improve
Postoperative Assessment
W H Y I T I S D O N E (continued) W H A T I T T E L L S M E (continued)
• Coagulation studies: Vari ous studies may be done, such as platelet count and bleeding and clotting time.
Post- CPB bleeding is caused by vari ous factors, including hemodilution, heparin use, platelet dysfunction due to exposure to the bypass pump, disseminated intravascular coagulation, and induced hypothermia (Shea, 2016). Patients placed on CPB equipment are more likely to bleed excessively than those who have off- bypass cardiac surgery. Risk increases further if the patient remains on bypass for more than 2.5 hours (Steiner &
Despotis, 2007).
• Electrolytes: A substance that, in solution, conducts an electric current and is decomposed by its passage. Sodium (Na), potassium (K+), and calcium (Ca) are common electrolytes.
Imbalances— hyperkalemia or hypokalemia, hypernatremia or hyponatremia, and hypocalcemia— can affect cardiac function and fl uid balance.
• Arterial blood gases (ABGs): Assessment of levels of oxygen (PaO2) and carbon dioxide (PaCO2).
Verifi es oxygenation status, effectiveness of respiratory function, and acid- base balance.
• Blood urea nitrogen (BUN) and creatinine (Cr): Elevated BUN can occur with dehydration, shock due to blood loss, or any condition that decreases blood fl ow to the kidneys.
Provides good evidence of the fi ltering function of the kidneys and a mea sure of the degree of systemic hydration.
• Glucose: Blood glucose levels should be controlled in all patients with diabetes to avoid hyperglycemia perioperatively.
Fluctuations may occur because of preoperative nutritional status, presence of organ dysfunction, and impact of IV infusions.
• Cardiac enzyme and isoenzymes troponin I (cTnI) and troponin T (cTnT): Contractile proteins with nearly absolute myo car dial tissue specifi city, as well as high sensitivity.
Troponins increase within 3 to 4 hours of myo car dial injury.
Elevated in the presence of acute, recent, or perioperative myo car dial infarction (MI).
Other Diagnostic Studies
• Chest x- ray: Evaluates organs and structures within the chest. Reveals heart size and position, pulmonary vasculature, and changes indicative of pulmonary complications, such as atelectasis or pulmonary edema. Verifi es condition of valve prosthesis and sternal wires, position of pacing leads, and intravascular or cardiac lines.
• Electrocardiogram (ECG): Rec ord of the electrical activity of the heart.
Identifi es changes in electrical and mechanical function such as might occur in immediate postoperative phase, acute or perioperative MI, valve dysfunction, and pericarditis.
D I A G N O S T I C S T U D I E S ( P O S T O P E R A T I V E ) (contd.)
NURSING PRIORITIES
1. Support hemodynamic stability and ventilatory function.
2. Promote relief of pain and discomfort.
3. Promote healing.
4. Provide information about postoperative expectations and treatment regimen.
DISCHARGE GOALS
1. Activity tolerance adequate to meet self- care needs.
2. Pain alleviated or managed.
3. Complications prevented or minimized.
4. Incisions healing.
5. Postdischarge medi cations, exercise, diet, and therapy understood.
6. Plan in place to meet needs after discharge.
N U R S I N G D I A G N O S I S :
risk for decreased Cardiac Output
Possibly Evidenced by
Alteration in heart rate or rhythm
Altered preload [e.g., decreased venous return]
Altered afterload [e.g., systemic vascular re sis tance]
ACTIONS/INTERVENTIONS RATIONALE
Hemodynamic Regulation NIC In de pen dent
Monitor and document trends in heart rate and BP, espe- cially noting hypertension. Be aware of specific systolic and diastolic limits defined for client.
Tachycardia is a common response to discomfort, inad- equate blood or fluid replacement, and the stress of surgery. However, sustained tachycardia increases cardiac workload and can decrease effective cardiac output.
Hypotension may result 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 vari ous complications.
Monitor and document cardiac dysrhythmias. Hypothermia, electrolyte and metabolic disturbances, manual manipulation of the heart, and myo car dial ischemia may be factors in postoperative dysrhythmias.
The incidence of atrial fibrillation (AF) ranges from 15% to 30% depending on many factors, including preoperative history and medi cations and type of surgery performed (El- Chami, 2013).
Observe client response to dysrhythmias, such as drop in BP, chest pain, and dyspnea.
Decreased cardiac output and hemodynamic compromise that occur with dysrhythmias require prompt intervention.
Observe for bleeding from incisions and chest tube (if in place).
Helps identify bleeding complications that can reduce circulating volume, organ perfusion, and cardiac function.
Observe for changes in usual mental status, orientation, and body movement or reflexes, such as onset of confusion, disorientation, restlessness, reduced response to stimuli, and stupor.
May indicate decreased ce re bral blood flow or systemic oxygenation because of diminished cardiac output—
sustained or severe dysrhythmias, low BP, heart failure, or thromboembolic phenomena, including perioperative stroke.
Rec ord skin temperature and color and quality and equality of peripheral pulses.
Warm, pink skin and strong, equal pulses are general indicators of adequate cardiac output.
Mea sure and document intake and output (I&O) and calculate fluid balance.
Useful in determining fluid needs or identifying fluid excesses, which can compromise cardiac output and oxygen consumption.
Schedule uninterrupted rest and sleep periods. Assist with self- care activities as needed.
Prevents fatigue or exhaustion and excessive cardiovascular stress.
Monitor graded activity program. Note client response; vital signs before, during, and after activity; and development of dysrhythmias.
Regular exercise stimulates circulation and promotes feeling of well- being. Progression of activity depends on cardiac tolerance.
Inspect for JVD, peripheral or dependent edema, congestion in lungs, shortness of breath, and change in mental status.
May be indicative of acute or chronic heart failure.
Investigate reports of angina or severe chest pain accompa- nied by restlessness, diaphoresis, and ECG changes.
Although not a common complication of CABG, periopera- tive or postoperative MI can occur.
Investigate and report profound hypotension and unrespon- siveness to fluid challenge, tachycardia, distant heart sounds, and stupor or coma.
Development of cardiac tamponade can rapidly pro gress to cardiac 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 immediate postoperative period but can occur later in the recovery phase.
N U R S I N G D I A G N O S I S :
risk for decreased Cardiac Output
(continued)Desired Outcomes/Evaluation Criteria— Client Will Cardiac Pump Effectiveness NOC
Maintain hemodynamic stability, such as vital signs and cardiac output within normal range, adequate urinary output, decreased frequency or absence of dysrhythmias; absence of venous stasis complications.
CHAPTER 2Cardiovascular: Cardiac Surgeries
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
Collaborative
Review serial ECGs. Most frequently done to follow the pro gress in normalization
of electrical conduction patterns and ventricular function after surgery or to identify complications such as peri- operative MI.
Mea sure cardiac output and other functional par ameters, as indicated.
Useful in evaluating response to therapeutic interventions and identifying need for more aggressive or emergency care.
Monitor Hgb, Hct, and coagulation studies, such as activated prothrombin time (aPTT), international normalized ratio (INR), activated clotting time (ACT), and platelet count.
Help to identify bleeding or clotting prob lems 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 concen- tration of coagulation factors, fibrinogen, and platelets. In addition, the use of hypothermia during surgery to decrease tissue oxygen requirements slows down the pro cess of clotting and decreases platelet function.
Administer intravenous (IV) fluids or blood products as needed.
Clients who have surgery on CPB equipment are more likely to bleed excessively than those who have off- bypass cardiac surgery. RBC replacement is often indicated to restore and maintain adequate circulating volume and enhance oxygen- carrying capacity. IV fluids may be discontinued before discharge from the ICU or may remain in place for fluid replacement and emergency cardiac medi cations.
Administer supplemental oxygen as appropriate. Promotes maximal oxygenation to reduce cardiac workload and aid in resolving myo car dial irritability and
dysrhythmias.
Administer electrolytes and medi cations, as indicated, such as potassium, antidysrhythmics, inotropic agents, diuretics, and anticoagulants.
Client needs are variable, depending on type of surgery, client’s response to surgical intervention, and preexisting conditions, such as general health and type of heart disease. Electrolytes, antidysrhythmics, and other heart medi cations may be required on a short- term or long- term basis to maximize cardiac contractility and output.
Maintain surgically placed pacing wires (atrial or ventricular) and initiate pacing if indicated.
May be required to support cardiac output in presence of conduction disturbances (severe dysrhythmias) that compromise 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 be hav ior
Expressive be hav iors— restlessness, irritability Changes in heart rate, blood pressure, respiratory rate Desired Outcomes/Evaluation Criteria— Client Will Pain Level NOC
Verbalize relief or absence of pain.
Demonstrate relaxed body posture and ability to rest and sleep appropriately.
Pain Control NOC
Differentiate surgical discomfort from angina or preoperative heart pain.
ACTIONS/INTERVENTIONS RATIONALE
Pain Management: Acute NIC In de pen dent
Note type and location of incision(s). Many CABG clients do not experience severe discomfort in chest incision and may complain more often of donor site incision discomfort. Newer procedures, such as MIDCAB, require smaller chest and leg incisions, with less signifi- cant pain. Severe pain in either area should be investi- gated further for pos si ble complications.
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.
Pain is perceived, manifested, and tolerated individually. It is impor tant for client to differentiate incisional pain from other types of chest pain, such as angina or discomfort from chest tubes.
Observe for anxiety, irritability, crying, restlessness, and sleep disturbances.
These nonverbal cues may indicate the presence or degree of pain being experienced.
Monitor vital signs. Heart rate usually increases with acute pain, although a
bradycardic 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 myo car dial damage is occurring.
Identify and promote position of comfort, using adjuncts as necessary.
Pillows or blanket rolls are useful in supporting extremities, maintaining body alignment, and splinting incisions to reduce muscle tension and promote comfort.
Provide comfort mea sures, such as back rubs and position changes; assist with self- care activities; and encourage diversional activities, as indicated.
May promote relaxation, redirect attention, and reduce analgesic dosage or frequency.
Schedule care activities to balance with adequate periods of sleep and rest.
Rest and sleep are vital for cardiac healing (balance between oxygen demand and consumption) and can enhance coping with stress and discomfort.
Identify and encourage use of be hav iors such as guided imagery, distractions, visualizations, and deep breathing.
Relaxation techniques aid in management of stress, promote sense of well- being, may reduce analgesic needs, and promote healing.
Tell client to request analgesics as soon as discomfort becomes noticeable.
Presence of pain causes muscle tension, which can impair circulation, slow healing pro cess, and intensify pain.
Medicate before procedures and activities, as indicated. Client participation in respiratory treatments, ambulation, and procedures, such as removal of chest tubes, pace- maker wires, and sutures, are facilitated by maximum analgesic blood level.
Investigate reports of pain in unusual areas— for instance, calf of leg or abdomen—or vague complaints of discomfort, especially when accompanied by changes in mentation, vital signs, and respiratory rate.
May be an early manifestation of developing complication, such as thrombophlebitis, infection, and gastrointestinal dysfunction.
Note reports of pain or numbness in ulnar area (fourth and fifth digits) of the hand, often accompanied by pain and discomfort of the arms and shoulders. Tell client that the prob lem usually resolves with time.
Indicative of a stretch injury of the brachial plexus because of the position of the arms during surgery. No specific treatment is currently useful.
Collaborative
Administer analgesic medi cations (e.g., opioids, 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 promotes healing. Note: IV narcotics will be used during the immediate postoperative period. Oral narcotics will most likely still be required for some time after extuba- tion. Narcotic- induced respiratory depression is a risk during this time, requiring vigilant monitoring of client’s respiratory status.
CHAPTER 2Cardiovascular: Cardiac Surgeries
ACTIONS/INTERVENTIONS RATIONALE
Respiratory Monitoring NIC In de pen dent
Evaluate respiratory rate and depth. Note respiratory effort;
for example, presence of dyspnea, use of accessory muscles, and nasal flaring.
Client responses are variable. Respiratory rate and effort may be altered by pain, fear, fever, blood or fluid loss, accumu- lation of secretions, hypoxia, or gastric distention.
Respiratory suppression can occur from long time under anesthesia or heavy use of opioid analgesics. Early recognition and treatment of abnormal ventilation may prevent complications.
Auscultate breath sounds. Note areas of diminished or absent breath sounds and presence of adventitious sounds, such as crackles or rhonchi.
Breath sounds are often diminished in lung bases for a period after surgery because of normally occurring atelectasis. Loss of active breath sounds in an area of previous ventilation may reflect collapse of the lung segment, especially if chest tubes have recently been removed. Crackles or rhonchi may be indicative of fluid accumulation due to interstitial edema, pulmonary edema, or infection, or partial airway obstruction with pooling of secretions.
Observe chest excursion. Investigate decreased expansion or lack of symmetry in chest movement.
Air or fluid in the pleural space prevents complete expansion (usually on one side) and requires further assessment of ventilation status.
Observe character of cough and sputum production. Frequent coughing may simply be throat irritation from operative endotracheal tube (ET) placement or can reflect pulmonary congestion. Purulent sputum suggests onset of pulmonary infection.
Inspect skin and mucous membranes for cyanosis. Cyanosis of lips, nail beds, or earlobes or general duskiness may indicate a hypoxic condition due to heart failure or pulmonary complications. General pallor, commonly pres ent in the immediate postoperative period, may indicate anemia from blood loss or insufficient blood replacement or RBC destruction from CPB pump.
Elevate head of bed, place in upright or semi- Fowler’s position. Assist with early ambulation and increased time out of bed.
Enhances respiratory function and lung expansion. Effective in preventing and resolving pulmonary congestion.
Encourage client participation in and responsibility for deep- breathing exercises, use of adjuncts (e.g., incentive spirometer), and coughing, as indicated.
Aids in lung re- expansion and maintaining patency of small airways, especially after removal of chest tubes. Coughing is not necessary unless wheezes and rhonchi are pres ent, indicating retention of secretions.
Demonstrate and reinforce splinting chest with pillows during deep breathing or coughing.
Reduces incisional tension, promotes maximal lung expan- sion, and may enhance effectiveness of cough effort.
Explain that coughing and respiratory treatments will not loosen or damage grafts or reopen chest incision.
Provides reassurance that injury will not occur and may enhance cooperation with therapeutic regimen.
Encourage maximal fluid intake within cardiac reserves. Adequate hydration helps liquefy secretions, facilitating expectoration.
N U R S I N G D I A G N O S I S :
risk for in effec tive Breathing Pattern
Possibly Evidenced By Pain
Musculoskeletal impairment [surgical incision; chest tube]
Desired Outcomes/Evaluation Criteria— Client Will Respiratory Status: Ventilation NOC
Maintain an effective respiratory pattern free of cyanosis and other signs and symptoms of hypoxia, with breath sounds equal bilaterally, lung fields clearing.
Display complete re- expansion of lungs with absence of pneumothorax and hemothorax.
ACTIONS/INTERVENTIONS RATIONALE
Incision Site Care NIC In de pen dent
Inspect all incisions. Evaluate healing pro gress. Review expectations for healing with client.
Healing begins immediately, but complete healing takes time. Chest incision heals first (minimal muscle tissue), but donor site incision requires more time (more muscle tissue, longer incision, slower circulation). As healing progresses, the incision lines may appear dry, with crusty scabs. Under lying tissue may look bruised and feel tense, warm, and lumpy, suggesting resolving hematoma.
Suggest wearing soft cotton shirts and loose- fitting clothing, leaving incisions open to air as much as pos si ble, covering and padding portion of incisions as necessary.
Reduces suture line irritation and pressure from clothing.
Leaving incisions open to air promotes healing pro cess and may reduce risk of infection.
Have client shower in warm water, washing incisions gently.
Instruct client to avoid tub baths until approved by physician.
Keeps incision clean and promotes circulation and healing.
Note: Climbing out of tub requires use of arms and pectoral muscles, which can put undue stress on sternotomy.
Encourage ankle exercises and elevation of legs when sitting in chair.
Promotes circulation and reduces edema to improve tissue healing.
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
Medicate with analgesic before respiratory treatments, as indicated.
Allows for easier chest movement and reduces discomfort related to incisional pain, facilitating client cooperation with and effectiveness of respiratory treatments.
Rec ord response to deep- breathing exercises or other respiratory treatment, noting breath sounds before and after treatment, as well as cough and sputum production.
Documents effectiveness of therapy or need for more aggressive interventions.
Investigate and report respiratory distress, diminished or absent breath sounds, tachycardia, severe agitation, and drop in BP.
Although not a common complication, hemothorax or pneumothorax may occur following removal of chest tubes and requires prompt intervention.
Collaborative
Review chest x- ray reports, pulse oximetry, and laboratory studies (such as ABGs, Hgb), as indicated.
Monitors effectiveness of respiratory therapy and documents developing complications. A blood transfusion may be needed if blood loss is the reason for respiratory hypoxemia.
Instruct in and encourage use of incentive spirometer. Maximizes lung inflation, reduces atelectasis, and prevents pulmonary complications.
Administer supplemental oxygen by cannula or mask, as indicated.
Enhances oxygen delivery to the lungs for circulatory uptake, especially in the presence of reduced and altered
ventilation.
Assist with reinsertion of chest tubes or thoracentesis if indicated.
Re- expands lung by removal of accumulated blood and air and restoration of negative pleural pressure.
N U R S I N G D I A G N O S I S :
impaired Skin/Tissue Integrity
May Be Related To Surgical procedure Possibly Evidenced By
Disruption of skin surface/damaged tissue [surgical incisions, puncture wounds]
Desired Outcomes/Evaluation Criteria— Client Will Wound Healing: Primary Intention NOC
Demonstrate be hav iors and techniques to promote healing and prevent complications.
Display timely wound healing.
(continues on page 108)
CHAPTER 2Cardiovascular: Cardiac Surgeries