chapter 14: nursing management: patients with coronary vascular

Chapter 14: Nursing Management: Patients With Coronary Vascular Disorders

*The following is a sample care plan meant for adaptation. Always revise to meet your facility’s protocols and the latest research and nursing diagnoses.

PLAN OF NURSING CARE

Care of the Patient After Cardiac Surgery

NURSING DIAGNOSIS: Decreased cardiac output related to blood loss and compromised

myocardial function

GOAL: Restoration of cardiac output to maintain organ and tissue perfusion

Nursing Interventions Rationale Expected Outcomes

1. Monitor cardiovascular

status. Serial readings

of blood pressure, other

hemodynamic

parameters, and cardiac

rhythm and rate are

obtained, recorded, and

correlated with the

patient’s overall

condition.

1. Effectiveness of cardiac

output is determined by

continuous monitoring.

● The following

parameters are within

the patient’s normal

ranges:

Arterial pressure

CVP

Pulmonary artery

pressures

PAWP

Heart sounds

a. Assess arterial blood

pressure every 15

minutes until stable;

then arterial or cuff

a. Blood pressure is

one of the most

important physiologic

parameters to

Pulmonary and systemic

vascular resistance

Cardiac output and

cardiac index

blood pressure every

1 to 4 hours × 24

hours; then every 8

to 12 hours until

hospital discharge.

monitor;

vasoconstriction

after

cardiopulmonary

bypass may require

treatment with an IV

vasodilator.

Peripheral pulses

Cardiac rate and rhythm

Cardiac biomarkers

Urine output

b. Auscultate for heart

sounds and rhythm.

b. Auscultation

provides evidence of

cardiac tamponade

(muffled distant heart

sounds), pericarditis

(precordial rub),

arrhythmias.

Skin and mucosal color

Skin temperature

c. Assess peripheral

pulses (pedal, tibial,

radial).

c. Presence or

absence and quality

of pulses provide

data about cardiac

output as well as

obstructive lesions.

d. Monitor

hemodynamic

parameters to

d. Rising CVP and

PAWP may indicate

congestive heart

assess cardiac

output, volume

status, and vascular

tone.

failure or pulmonary

edema. Low

pressures may

indicate need for

volume replacement.

e. Watch for trends in

hemodynamics and

note that mechanical

ventilation may alter

hemodynamics.

e. Trends are more

important than

isolated readings.

Mechanical

ventilation increases

intrathoracic

pressure.

f. Monitor ECG pattern

for cardiac

arrhythmias and

ischemic changes.

f. Arrhythmias may

occur with coronary

ischemia, hypoxia,

bleeding, acid-base

or electrolyte

disturbances,

digitalis toxicity, or

cardiac failure. ST-

segment changes

may indicate

myocardial ischemia.

Pacemaker capture

and antiarrhythmic

medications are

used to maintain

heart rate and

rhythm and to

support blood

pressure.

g. Assess cardiac

biomarker results.

g. Elevations may

indicate myocardial

infarction.

h. Measure urine

output every half

hour to 1 hour at

first, then with vital

signs.

h. Urine output less

than 30 mL/h

indicates decreased

renal perfusion and

may reflect

decreased cardiac

output.

i. Observe buccal

mucosa, nail beds,

lips, earlobes, and

extremities.

i. Duskiness and

cyanosis may

indicate decreased

cardiac output.

j. Assess skin; note j. Cool moist skin

temperature and

color.

indicates

vasoconstriction and

decreased cardiac

output.

2. Observe for persistent

bleeding: excessive

chest tube drainage of

blood; hypotension; low

CVP; tachycardia.

Prepare to administer

blood products, IV

solutions.

2. Bleeding can result from

surgical trauma to

tissues, anticoagulant

medications, and

clotting defects.

● Less than 200 mL/h of

drainage through chest

tubes during first 4 to 6

hours.

● Vital signs stable.

3. Observe for cardiac

tamponade:

hypotension; rising CVP

and PAWP, pulsus

paradoxus; muffled

heart sounds; weak,

thready pulse; jugular

vein distention;

decreasing urinary

output. Check for

diminished amount of

3. Cardiac tamponade

results from bleeding

into the pericardial sac

or accumulation of fluid

in the sac, which

compresses the heart

and prevents adequate

filling of the ventricles.

Decrease in chest

drainage may indicate

that fluid and clots are

● CVP and other

hemodynamic

parameters within

normal limits.

● Urinary output within

normal limits.

● Skin color normal.

● Respirations unlabored,

clear breath sounds.

● Pain limited to incision.

blood in chest drainage

collection system.

Prepare for reoperation.

accumulating in the

pericardial sac.

4. Observe for signs of

cardiac failure. Prepare

to administer diuretics,

digoxin, IV inotropic

agents.

4. Cardiac failure results

from decreased

pumping action of the

heart; can cause

deficient perfusion to

vital organs.

NURSING DIAGNOSIS: Impaired gas exchange related to chest surgery

GOAL: Adequate gas exchange


1. Maintain mechanical

ventilation until the

patient is able to

breathe independently.

1. Ventilatory support is

used to decrease work

of the heart, to maintain

effective ventilation, and

to provide an airway in

the event of

complications.

● Airway patent.

● ABGs within normal

range.

● Endotracheal tube

correctly placed, as

evidenced by x-ray.

2. Monitor arterial blood

gases, tidal volume,

peak inspiratory

pressure, and

2. ABGs and ventilator

parameters indicate

effectiveness of

ventilator and changes

● Breath sounds clear

bilaterally.

● Ventilator synchronous

with respirations.

extubation parameters. that need to be made to

improve gas exchange.

● Breath sounds clear

after

suctioning/coughing.

3. Auscultate chest for

breath sounds.

3. Crackles indicate

pulmonary congestion;

decreased or absent

breath sounds may

indicate pneumothorax,

hemothorax,

dislodgement of tube.

● Nail beds and mucous

membranes pink.

● Mental acuity consistent

with amount of

sedatives and

analgesics received.

● Oriented to person; able

to respond yes and no

appropriately.

4. Sedate patient

adequately, as

prescribed, and monitor

respiratory rate and

depth.

4. Sedation helps the

patient to tolerate the

endotracheal tube and

to cope with ventilatory

sensations.

● Able to be weaned

successfully from

ventilator.

5. Suction

tracheobronchial

secretions as needed,

using strict aseptic

technique.

5. Retention of secretions

leads to hypoxia and

possible infection.

6. Assist in weaning and 6. Extubation decreases

endotracheal tube

removal.

risk of pulmonary

infections and enhances

ability of patient to

communicate.

7. After extubation,

promote deep breathing,

coughing, and turning.

Encourage use of the

incentive spirometer and

compliance with

breathing treatments.

Teach incisional

splinting with a “cough

pillow” to decrease

discomfort.

7. Aids in keeping airway

patent, preventing

atelectasis, and

facilitating lung

expansion.

NURSING DIAGNOSIS: Risk for imbalanced fluid volume and electrolyte imbalance related

to alterations in blood volume

GOAL: Fluid and electrolyte balance


1. Monitor fluid and

electrolyte balance.

1. Adequate circulating

blood volume is

necessary for optimal

cellular activity; fluid and

● Fluid intake and output

balanced.

● Hemodynamic

assessment parameters

electrolyte imbalance

can occur after surgery.

negative for fluid

overload or

hypovolemia.

a. Accurately document

intake and output;

record urine volume

every half hour to 4

hours while in critical

care unit; then every

8 to 12 hours while

hospitalized.

a. Provides a method

to determine positive

or negative fluid

balance and fluid

requirements.

b. Assess blood

pressure,

hemodynamic

parameters, weight,

electrolytes,

hematocrit, jugular

venous pressure,

breath sounds,

urinary output, and

nasogastric tube

drainage.

b. Provides information

about state of

hydration.

● Normal blood pressure

with position changes.

● Absence of arrhythmia.

● Stable weight.

● Arterial blood pH 7.35 to

7.45.

● Serum potassium 3.5 to

5.0 mEq/L (3.5 to 5.0

mmol/L).

c. Measure c. Excessive blood loss ● Serum magnesium 1.3

postoperative chest

drainage; cessation

of drainage may

indicate kinked or

blocked chest tube.

Ensure patency and

integrity of the

drainage system.

Maintain

autotransfusion

system if in use.

from chest cavity can

cause hypovolemia.

to 2.3 mg/dL (0.62 to

0.95 mmol/L).

● Serum sodium 135 to

145 mEq/L (135 to 145

mmol/L).

● Serum calcium 8.6 to

10.2 mg/dL (2.15 to 2.55

mmol/L).

d. Weigh daily and

correlate with intake

and output.

d. Indicator of fluid

balance.

● Serum glucose less

than 110 mg/dL.

2. Be alert to changes in

serum electrolyte levels.

2. A specific concentration

of electrolytes is

necessary in both

extracellular and

intracellular body fluids

to sustain life.

a. Hypokalemia (low

potassium)

Effects: arrhythmias:

a. Causes: inadequate

intake, diuretics,

vomiting, excessive

PVCs, ventricular

tachycardia.

Observe for specific

ECG changes.

Administer IV

potassium

replacement as

prescribed.

nasogastric

drainage, stress from

surgery.

b. Hyperkalemia (high

potassium)

Effects: ECG

changes, tall peaked

T waves, wide QRS,

brachycardia. Be

prepared to

administer diuretic or

an ion-exchange

resin (sodium

polystyrene

sulfonate

[Kayexalate]); IV

sodium bicarbonate,

or IV insulin and

b. Causes: increased

intake, hemolysis

from

cardiopulmonary

bypass/mechanical

assist devices,

acidosis, renal

insufficiency. The

resin binds

potassium and

promotes intestinal

excretion of it. IV

sodium bicarbonate

drives potassium into

the cells from

glucose. extracellular fluid.

Insulin assists the

cells with glucose

and potassium

absorption.

c. Monitor serum

magnesium, sodium

and calcium.

c. Low levels of

magnesium are

associated with

arrhythmias, muscle

spasm, and tetany.

Low levels of sodium

are associated with

weakness and

neurological

symptoms. Low

levels of calcium can

lead to arrhythmias

and muscle spasm.

d. Hyperglycemia (high

blood glucose)

Effects: increased

urine output, thirst,

metabolic acidosis

d. Cause: stress

response to surgery.

Affects both patients

with diabetes and those

without diabetes.

Administer insulin as

prescribed.

NURSING DIAGNOSIS: Disturbed sensory perception related to excessive environmental

stimulation, sleep deprivation, physiological imbalance

GOAL: Reduction of symptoms of sensory perceptual imbalance; prevention of

postcardiotomy delirium


1. Use measures to

prevent postcardiotomy

delirium:

a. Explain all

procedures and the

need for patient

cooperation.

b. Plan nursing care to

provide for periods of

uninterrupted sleep

with patient’s normal

day–night pattern.

c. Promote continuity of

care.

d. Orient to time and

place frequently.

1. Postcardiotomy delirium

may result from anxiety,

sleep deprivation,

increased sensory input,

disorientation to night

and day. Normally,

sleep cycles are at least

50 minutes long. The

first cycle may be as

long as 90 to 120

minutes and then

shorten during

successive cycles.

Sleep deprivation

results when the sleep

cycles are interrupted or

● Cooperates with

procedures.

● Sleeps for long,

uninterrupted intervals.

● Oriented to person,

place, time.

● Experiences no

perceptual distortions,

hallucinations,

disorientation,

delusions.

Encourage family to

visit.

e. Assess for

medications that

may contribute to

delirium.

inadequate in number.

2. Observe for perceptual

distortions,

hallucinations,

disorientation, and

paranoid delusions.

2. Delirium can indicate a

serious medical

condition such as

hypoxia, acid-base

imbalance, metabolic

abnormalities, and

cerebral infarction.

NURSING DIAGNOSIS: Acute pain related to surgical trauma and pleural irritation caused

by chest tubes

GOAL: Relief of pain


1. Record nature, type,

location, intensity, and

duration of pain.

1. Pain and anxiety

increase pulse rate,

oxygen consumption,

and cardiac workload.

● States pain is

decreasing in severity.

● Reports absence of

pain.

● Restlessness

decreased.

2. Encourage routine pain

medication dosing for

the first 24 to 72 hours

and observe for side

effects of lethargy,

hypotension,

tachycardia, respiratory

depression.

2. Analgesia promotes

rest, decreases oxygen

consumption caused by

pain, and aids patient in

performing deep-

breathing and coughing

exercises; pain

medications is more

effective when taken

before pain is severe.

● Vital signs stable.

● Participates in deep-

breathing and coughing

exercises.

● Verbalizes fewer

complaints of pain each

day.

● Positions self;

participates in care

activities.

● Gradually increases

activity.

NURSING DIAGNOSIS: Ineffective renal tissue perfusion related to decreased cardiac

output, hemolysis, or vasopressor drug therapy

GOAL: Maintenance of adequate renal perfusion


1. Assess renal function: 1. Renal injury can be

caused by deficient

perfusion, hemolysis,

low cardiac output, and

use of vasopressor

agents to increase blood

pressure.

● Urine output consistent

with fluid intake; greater

than 30 mL/h.

● Urine specific gravity

1.003 to 1.030.

a. Measure urine

output every half

hour to 4 hours in

critical care then

every 8 to 12 hours

until hospital

discharge.

a. Less than 30 mL/h

indicates decreased

renal function.

● BUN, creatinine,

electrolytes within

normal limits.

b. Monitor and report

lab results: BUN,

serum creatinine,

serum electrolytes.

b. Indicate kidneys’

ability to excrete

waste products.

2. Prepare to administer

rapid-acting diuretics or

inotropic drugs (eg,

dobutamine).

2. Promote renal function

and increase cardiac

output and renal blood

flow.

3. Prepare patient for

dialysis or continuous

renal replacement

therapy if indicated.

3. Provides patient with the

opportunity to ask

questions and prepare

for the procedure.

NURSING DIAGNOSIS: Ineffective thermoregulation related to infection or

postpericardiotomy syndrome

GOAL: Maintenance of normal body temperature


1. Assess temperature

every hour.

1. Fever can indicate

infectious or

inflammatory process.

● Normal body

temperature.

2. Use aseptic technique

when changing

dressings, suctioning

endotracheal tube;

maintain closed systems

for all intravenous and

arterial lines and for

indwelling urinary

catheter.

2. Decreases risk of

infection.

● Incisions are free of

infection and are

healing.

● Absence of symptoms

of postpericardiotomy

syndrome: fever,

malaise, pericardial

effusion, pericardial

friction rub, arthralgia.

3. Observe for symptoms

of postpericardiotomy

syndrome.

3. Occurs in approximately

10% of patients after

cardiac surgery.

4. Obtain cultures and

other lab work (CBC,

ESR); administer

antibiotics as

prescribed.

4. Antibiotics treat

documented infection.

5. Administer anti-

inflammatory agents as

directed.

5. Relieve symptoms of

inflammation.

NURSING DIAGNOSIS: Deficient knowledge about self-care activities

GOAL: Ability to perform self-care activities


1. Develop teaching plan

for patient and family.

Provide specific

instructions for the

following:

● Diet and daily

weights

● Activity progression

● Exercise

● Deep breathing,

coughing, lung

expansion exercises

● Temperature

monitoring

● Medication regimen

● Pulse taking

● Access to the

emergency medical

system

1. Each patient will have

unique learning needs.

● Patient and family

members explain and

comply with therapeutic

regimen.

● Patient and family

members identify

necessary lifestyle

changes.

● Has copy of discharge

instructions (in the

patient’s primary

language and at

appropriate reading

level; has an alternate

format if indicated).

● Keeps follow-up

appointments.

2. Provide verbal and 2. Repetition promotes

written instructions;

provide several teaching

sessions for

reinforcement and

answering questions.

learning by allowing for

questions and

clarification of

misinformation.

3. Involve family in

teaching sessions.

3. Family members

responsible for home

care are usually anxious

and require adequate

time for learning.

4. Provide contact

information for surgeon

and cardiologist and

instructions about

follow-up visit with

surgeon.

4. Arrangements for

contacts with health

care personnel help to

allay anxieties.

5. Make appropriate

referrals: home care

agency, cardiac

rehabilitation program,

community support

groups.

5. Learning, recovery and

lifestyle changes

continue after discharge

from the hospital.

chapter 14: nursing management: patients with coronary vascular

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