CARE SETTING
Inpatient acute hospital on a surgical or post-ICU step-down unit.
RELATED CONCERNS
- Angina
- Heart failure: chronic
- Dysrhythmias
- Myocardial infarction
- Hemothorax/pneumothorax
- Psychosocial aspects of care
- Surgical intervention
- Patient Assessment Database
- The preoperative data presented here depend on the specific disease process and underlying cardiac condition/reserve.
ACTIVITY/REST
May report:
- History of exercise intolerance
- Generalized weakness, fatigue
- Inability to perform expected/usual life activities
- Insomnia/sleep disturbance
May exhibit:
- Abnormal heart rate, BP changes with activity
- Exertional discomfort or dyspnea
- ECG changes/dysrhythmias
CIRCULATION
May report:
History of recent/acute MI, three (or more) vessel coronary artery disease, valvular heart disease, hypertension
May exhibit:
- Variations in BP, heart rate/rhythm
- Abnormal heart sounds: S3/S4, murmurs
- Pallor/cyanosis of skin or mucous membranes
- Cool/cold, clammy skin
- Edema, JVD
- Diminished peripheral pulses
- Abnormal breath sounds: crackles
- Restlessness/other changes in mentation or sensorium (severe cardiac decompensation)
EGO INTEGRITY
May report:
- Feeling frightened/apprehensive, helpless
- Distress over current events (anger/fear)
- Fear of death/eventual outcome of surgery, possible complications
- Fear about changes in lifestyle/role functioning
May exhibit:
- Apprehension, restlessness
- Facial/general tension; withdrawal/lack of eye contact
- Focus on self; hostility, anger; crying
- Changes in heart rate, BP, breathing patterns
FOOD/FLUID
May report:
- Change in weight
- Loss of appetite
- Abdominal pain, nausea/vomiting
- Change in urine frequency/amount
May exhibit:
- Weight gain/loss
- Dry skin, poor skin turgor
- Postural hypotension
- Diminished/absent bowel sounds
- Edema (generalized, dependent, pitting)
NEUROSENSORY
May report:
Fainting spells, vertigo
May exhibit:
Changes in orientation or usual response to stimuli
Restlessness; irritability, exaggerated emotional responses; apathy
PAIN/DISCOMFORT
May report:
Chest pain, angina
RESPIRATION
May report:
Shortness of breath
May exhibit:
Crackles
Productive cough
SAFETY
May report:
Infectious episode with valvular involvement or myopathy
TEACHING/LEARNING
May report:
- Familial risk factors of diabetes, heart disease, hypertension, strokes
- Use of various cardiovascular drugs
- Failure to improve
- Postoperative Assessment
PAIN/DISCOMFORT
May report:
Incisional discomfort
Pain/paresthesia of shoulders, arms, hands, legs
May exhibit:
- Guarding
- Facial mask of pain; grimacing
- Distraction behaviors; moaning; restlessness
- Changes in BP/pulse/respiratory rate
RESPIRATION
May report:
Inability to cough or take a deep breath
May exhibit:
- Decreased chest expansion
- Splinting/muscle guarding
- Dyspnea (normal response to thoracotomy)
- Areas of diminished or absent breath sounds (atelectasis)
- Anxiety
- Changes in ABGs/pulse oximetry
SAFETY
May exhibit:
Oozing/bleeding from chest or donor site incisions
TEACHING/LEARNING
- Discharge plan DRG projected mean length of inpatient stay: 4.7 days, acute care (additional days may be considerations: divided among multiple levels of care)
- Short-term assistance with food preparation, shopping, transportation, self-care needs, and homemaker/home maintenance tasks
- Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES (POSTOPERATIVE)
- Hemoglobin (Hb)/hematocrit (Hct): A low Hb reduces oxygen-carrying capacity and indicates need for red blood cell replacement. Elevation of Hct suggests dehydration/need for fluid replacement.
- Coagulation studies: Various studies may be done (e.g., platelet count, bleeding and clotting time) to determine therapeutic level of anticoagulant therapy when used.
- Electrolytes: Imbalances (hyperkalemia/hypokalemia, hypernatremia/hyponatremia, and hypocalcemia) can affect cardiac function and fluid balance.
- ABGs: Verifies oxygenation status, effectiveness of respiratory function, and acid-base balance.
- Pulse oximetry: Provides noninvasive measure of oxygenation at tissue level.
- BUN/creatinine: Reflects adequacy of renal and liver perfusion/function.
- Amylase: Elevation is occasionally seen in high-risk patients, e.g., those with heart failure undergoing valve replacement.
- Glucose: Fluctuations may occur because of preoperative nutritional status, presence of diabetes/organ dysfunction, rate of dextrose infusions.
- Cardiac enzymes/isoenzymes: Elevated in the presence of acute, recent, or perioperative MI.
- Chest x-ray: Reveals heart size and position, pulmonary vasculature, and changes indicative of pulmonary complications (e.g., atelectasis). Verifies condition of valve prosthesis and sternal wires, position of pacing leads, intravascular/cardiac lines.
- ECG: Identifies changes in electrical, mechanical function such as might occur in immediate postoperative phase, acute/perioperative MI, valve dysfunction, and/or pericarditis.
- Cardiac echocardiogram/catheterization: Measures chamber pressures and pressure gradients across valves, identifies occlusions of arteries, impaired coronary perfusion, and possible wall motion abnormalities.
- Transesophageal echocardiography: Useful in diagnosing cardiac valve and chamber abnormalities, such as regurgitation, shunting, or stenosis in patients in whom transthoracic approach is not feasible.
- Nuclear studies (e.g., thallium-201, DPY-thallium/Persantine): Heart scans demonstrate coronary artery disease, heart chamber dimensions, and presurgical/postsurgical functional capabilities.
NURSING PRIORITIES
- Support hemodynamic stability/ventilatory function.
- Promote relief of pain/discomfort.
- Promote healing.
- Provide information about postoperative expectations and treatment regimen.
DISCHARGE GOALS
- Activity tolerance adequate to meet self-care needs.
- Pain alleviated/managed.
- Complications prevented/minimized.
- Incisions healing.
- Postdischarge medications, exercise, diet, therapy understood.
- Plan in place to meet needs after discharge.
{ 0 komentar... Views All / Send Comment! }
Posting Komentar