Risk factors may include
Altered myocardial contractility secondary to temporary factors, such as ventricular wall surgery, recent MI, response to certain medications and drug interactions
Altered preload (hypovolemia) and afterload (systemic vascular resistance)
Altered heart rate or rhythm (dysrhythmias)
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Tissue Perfusion: Cardiac
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.
Nursing intervention with rationale:
1. Monitor and document trends in heart rate and BP, especially noting hypertension. Be aware of specific systolic and diastolic limits defined for client.
Rationale: Tachycardia is a common response to discomfort, inadequate 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 various complications.
2. Monitor and document cardiac dysrhythmias. Observe client response to dysrhythmias, such as drop in BP, chest pain, and dyspnea.
Rationale: Life-threatening dysrhythmias can occur because of electrolyte imbalance, myocardial ischemia, or alterations in the heart’s electrical conduction. Atrial fibrillation and atrial flutter are the most common dysrhythmias occurring around the second or third day after CABG (older clients or presence of right coronary artery disease increases risk). Decreased cardiac output and hemodynamic compromise that occur with dysrhythmias require prompt intervention. Note: This is the most frequently occurring postoperative complication, often prolonging hospital stay.
3. Observe for bleeding from incisions and chest tube (if in place).
Rationale: Helps identify bleeding complications that can reduce circulating volume, organ perfusion, and cardiac function.
4. 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.
Rationale: May indicate decreased cerebral blood flow or oxygenation as a result of diminished cardiac output—sustained or severe dysrhythmias, low BP, heart failure, or thromboembolic phenomena.
5. Record skin temperature and color and quality and equality of peripheral pulses.
Rationale: Warm, pink skin and strong, equal pulses are general indicators of adequate cardiac output.
6. Measure and document intake and output (I&O) and calculate fluid balance.
Rationale: Useful in determining fluid needs or identifying fluid excesses, which can compromise cardiac output and oxygen consumption.
7. Schedule uninterrupted rest and sleep periods. Assist with self-care activities as needed.
Rationale: Prevents fatigue or exhaustion and excessive cardiovascular stress.
6. Monitor graded activity program. Note client response; vital signs before, during, and after activity; and development of dysrhythmias.
Rationale: Regular exercise stimulates circulation and promotes feeling of well-being. Progression of activity depends on cardiac tolerance.
7. Evaluate presence and degree of anxiety or emotional duress. Encourage the use of relaxation techniques such as deep breathing and diversional activities.
Rationale: Excessive or escalating emotional reactions can negatively affect vital signs and systemic vascular resistance, eventually affecting cardiac function.
8. Inspect for JVD, peripheral or dependent edema, congestion in lungs, shortness of breath, and change in mental status.
Rationale: May be indicative of acute or chronic heart failure.
9. Investigate reports of angina or severe chest pain accompanied by restlessness, diaphoresis, and ECG changes.
Rationale: Although not a common complication of CABG, perioperative or postoperative MI can occur.
10. Investigate and report profound hypotension and unresponsiveness to fluid challenge, tachycardia, distant heart sounds, and stupor or coma.
Rationale: Development of cardiac tamponade can rapidly progress 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.
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