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
1. Effectiveness of cardiac
● The following
status. Serial readings
output is determined by
parameters are within
of blood pressure, other
continuous monitoring.
the patient’s normal
hemodynamic
ranges:
parameters, and cardiac
Arterial pressure
rhythm and rate are
CVP
obtained, recorded, and
Pulmonary artery
correlated with the
pressures
patient’s overall
PAWP
condition.
Heart sounds
a. Assess arterial blood
a. Blood pressure is
pressure every 15
one of the most
minutes until stable;
important physiologic
then arterial or cuff
parameters to
Pulmonary and systemic
vascular resistance
Cardiac output and
cardiac index
blood pressure every
monitor;
Peripheral pulses
1 to 4 hours × 24
vasoconstriction
Cardiac rate and rhythm
hours; then every 8
after
Cardiac biomarkers
to 12 hours until
cardiopulmonary
Urine output
hospital discharge.
bypass may require
treatment with an IV
vasodilator.
b. Auscultate for heart
sounds and rhythm.
b. Auscultation
provides evidence of
cardiac tamponade
(muffled distant heart
sounds), pericarditis
(precordial rub),
arrhythmias.
c. Assess peripheral
c. Presence or
pulses (pedal, tibial,
absence and quality
radial).
of pulses provide
data about cardiac
output as well as
obstructive lesions.
d. Monitor
d. Rising CVP and
hemodynamic
PAWP may indicate
parameters to
congestive heart
Skin and mucosal color
Skin temperature
assess cardiac
failure or pulmonary
output, volume
edema. Low
status, and vascular
pressures may
tone.
indicate need for
volume replacement.
e. Watch for trends in
e. Trends are more
hemodynamics and
important than
note that mechanical
isolated readings.
ventilation may alter
Mechanical
hemodynamics.
ventilation increases
intrathoracic
pressure.
f. Monitor ECG pattern
f. Arrhythmias may
for cardiac
occur with coronary
arrhythmias and
ischemia, hypoxia,
ischemic changes.
bleeding, acid-base
or electrolyte
disturbances,
digitalis toxicity, or
cardiac failure. STsegment 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
g. Elevations may
biomarker results.
indicate myocardial
infarction.
h. Measure urine
h. Urine output less
output every half
than 30 mL/h
hour to 1 hour at
indicates decreased
first, then with vital
renal perfusion and
signs.
may reflect
decreased cardiac
output.
i.
j.
Observe buccal
i.
Duskiness and
mucosa, nail beds,
cyanosis may
lips, earlobes, and
indicate decreased
extremities.
cardiac output.
Assess skin; note
j.
Cool moist skin
temperature and
indicates
color.
vasoconstriction and
decreased cardiac
output.
2. Observe for persistent
2. Bleeding can result from
● Less than 200 mL/h of
bleeding: excessive
surgical trauma to
drainage through chest
chest tube drainage of
tissues, anticoagulant
tubes during first 4 to 6
blood; hypotension; low
medications, and
hours.
CVP; tachycardia.
clotting defects.
● Vital signs stable.
Prepare to administer
blood products, IV
solutions.
3. Observe for cardiac
3. Cardiac tamponade
● CVP and other
tamponade:
results from bleeding
hemodynamic
hypotension; rising CVP
into the pericardial sac
parameters within
and PAWP, pulsus
or accumulation of fluid
normal limits.
paradoxus; muffled
in the sac, which
heart sounds; weak,
compresses the heart
thready pulse; jugular
and prevents adequate
● Skin color normal.
vein distention;
filling of the ventricles.
● Respirations unlabored,
decreasing urinary
Decrease in chest
output. Check for
drainage may indicate
diminished amount of
that fluid and clots are
● Urinary output within
normal limits.
clear breath sounds.
● Pain limited to incision.
blood in chest drainage
accumulating in the
collection system.
pericardial sac.
Prepare for reoperation.
4. Observe for signs of
4. Cardiac failure results
cardiac failure. Prepare
from decreased
to administer diuretics,
pumping action of the
digoxin, IV inotropic
heart; can cause
agents.
deficient perfusion to
vital organs.
NURSING DIAGNOSIS:
GOAL:
Impaired gas exchange related to chest surgery
Adequate gas exchange
Nursing Interventions
Rationale
Expected Outcomes
1. Maintain mechanical
1. Ventilatory support is
● Airway patent.
ventilation until the
used to decrease work
patient is able to
of the heart, to maintain
breathe independently.
effective ventilation, and
● ABGs within normal
range.
● Endotracheal tube
to provide an airway in
correctly placed, as
the event of
evidenced by x-ray.
complications.
2. Monitor arterial blood
2. ABGs and ventilator
gases, tidal volume,
parameters indicate
peak inspiratory
effectiveness of
pressure, and
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
● Nail beds and mucous
membranes pink.
● Mental acuity consistent
breath sounds may
with amount of
indicate pneumothorax,
sedatives and
hemothorax,
analgesics received.
dislodgement of tube.
● Oriented to person; able
to respond yes and no
appropriately.
4. Sedate patient
4. Sedation helps the
● Able to be weaned
adequately, as
patient to tolerate the
successfully from
prescribed, and monitor
endotracheal tube and
ventilator.
respiratory rate and
to cope with ventilatory
depth.
sensations.
5. Suction
5. Retention of secretions
tracheobronchial
leads to hypoxia and
secretions as needed,
possible infection.
using strict aseptic
technique.
6. Assist in weaning and
6. Extubation decreases
endotracheal tube
risk of pulmonary
removal.
infections and enhances
ability of patient to
communicate.
7. After extubation,
7. Aids in keeping airway
promote deep breathing,
patent, preventing
coughing, and turning.
atelectasis, and
Encourage use of the
facilitating lung
incentive spirometer and
expansion.
compliance with
breathing treatments.
Teach incisional
splinting with a “cough
pillow” to decrease
discomfort.
NURSING DIAGNOSIS:
Risk for imbalanced fluid volume and electrolyte imbalance related
to alterations in blood volume
GOAL:
Fluid and electrolyte balance
Nursing Interventions
Rationale
Expected Outcomes
1. Monitor fluid and
1. Adequate circulating
● Fluid intake and output
electrolyte balance.
blood volume is
necessary for optimal
cellular activity; fluid and
balanced.
● Hemodynamic
assessment parameters
electrolyte imbalance
negative for fluid
can occur after surgery.
overload or
hypovolemia.
a. Accurately document
a. Provides a method
intake and output;
to determine positive
record urine volume
or negative fluid
every half hour to 4
balance and fluid
hours while in critical
requirements.
care unit; then every
8 to 12 hours while
hospitalized.
b. Assess blood
b. Provides information
pressure,
about state of
hemodynamic
hydration.
● Normal blood pressure
with position changes.
● Absence of arrhythmia.
parameters, weight,
● Stable weight.
electrolytes,
● Arterial blood pH 7.35 to
hematocrit, jugular
7.45.
● Serum potassium 3.5 to
venous pressure,
breath sounds,
5.0 mEq/L (3.5 to 5.0
urinary output, and
mmol/L).
nasogastric tube
drainage.
c. Measure
c. Excessive blood loss
● Serum magnesium 1.3
postoperative chest
from chest cavity can
to 2.3 mg/dL (0.62 to
drainage; cessation
cause hypovolemia.
0.95 mmol/L).
● Serum sodium 135 to
of drainage may
indicate kinked or
145 mEq/L (135 to 145
blocked chest tube.
mmol/L).
● Serum calcium 8.6 to
Ensure patency and
integrity of the
10.2 mg/dL (2.15 to 2.55
drainage system.
mmol/L).
Maintain
autotransfusion
system if in use.
d. Weigh daily and
correlate with intake
d. Indicator of fluid
balance.
and output.
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
a. Causes: inadequate
potassium)
intake, diuretics,
Effects: arrhythmias:
vomiting, excessive
● Serum glucose less
than 110 mg/dL.
PVCs, ventricular
nasogastric
tachycardia.
drainage, stress from
Observe for specific
surgery.
ECG changes.
Administer IV
potassium
replacement as
prescribed.
b. Hyperkalemia (high
b. Causes: increased
potassium)
intake, hemolysis
Effects: ECG
from
changes, tall peaked
cardiopulmonary
T waves, wide QRS,
bypass/mechanical
brachycardia. Be
assist devices,
prepared to
acidosis, renal
administer diuretic or
insufficiency. The
an ion-exchange
resin binds
resin (sodium
potassium and
polystyrene
promotes intestinal
sulfonate
excretion of it. IV
[Kayexalate]); IV
sodium bicarbonate
sodium bicarbonate,
drives potassium into
or IV insulin and
the cells from
glucose.
extracellular fluid.
Insulin assists the
cells with glucose
and potassium
absorption.
c. Monitor serum
c. Low levels of
magnesium, sodium
magnesium are
and calcium.
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
d. Cause: stress
blood glucose)
response to surgery.
Effects: increased
Affects both patients
urine output, thirst,
with diabetes and those
metabolic acidosis
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
Nursing Interventions
Rationale
Expected Outcomes
1. Use measures to
1. Postcardiotomy delirium
● Cooperates with
prevent postcardiotomy
may result from anxiety,
delirium:
sleep deprivation,
a. Explain all
increased sensory input,
procedures and the
disorientation to night
need for patient
and day. Normally,
cooperation.
sleep cycles are at least
b. Plan nursing care to
procedures.
● Sleeps for long,
uninterrupted intervals.
● Oriented to person,
place, time.
● Experiences no
50 minutes long. The
perceptual distortions,
provide for periods of
first cycle may be as
hallucinations,
uninterrupted sleep
long as 90 to 120
disorientation,
with patient’s normal
minutes and then
delusions.
day–night pattern.
shorten during
c. Promote continuity of
care.
d. Orient to time and
place frequently.
successive cycles.
Sleep deprivation
results when the sleep
cycles are interrupted or
Encourage family to
inadequate in number.
visit.
e. Assess for
medications that
may contribute to
delirium.
2. Observe for perceptual
2. Delirium can indicate a
distortions,
serious medical
hallucinations,
condition such as
disorientation, and
hypoxia, acid-base
paranoid delusions.
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
Nursing Interventions
Rationale
Expected Outcomes
1. Record nature, type,
1. Pain and anxiety
● States pain is
location, intensity, and
increase pulse rate,
duration of pain.
oxygen consumption,
and cardiac workload.
decreasing in severity.
● Reports absence of
pain.
● Restlessness
decreased.
2. Encourage routine pain
2. Analgesia promotes
● Vital signs stable.
● Participates in deep-
medication dosing for
rest, decreases oxygen
the first 24 to 72 hours
consumption caused by
breathing and coughing
and observe for side
pain, and aids patient in
exercises.
effects of lethargy,
performing deep-
hypotension,
breathing and coughing
complaints of pain each
tachycardia, respiratory
exercises; pain
day.
depression.
medications is more
● Verbalizes fewer
● Positions self;
effective when taken
participates in care
before pain is severe.
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
Nursing Interventions
Rationale
Expected Outcomes
1. Assess renal function:
1. Renal injury can be
● Urine output consistent
caused by deficient
with fluid intake; greater
perfusion, hemolysis,
than 30 mL/h.
low cardiac output, and
use of vasopressor
agents to increase blood
pressure.
● Urine specific gravity
1.003 to 1.030.
a. Measure urine
a. Less than 30 mL/h
● BUN, creatinine,
output every half
indicates decreased
electrolytes within
hour to 4 hours in
renal function.
normal limits.
critical care then
every 8 to 12 hours
until hospital
discharge.
b. Monitor and report
b. Indicate kidneys’
lab results: BUN,
ability to excrete
serum creatinine,
waste products.
serum electrolytes.
2. Prepare to administer
2. Promote renal function
rapid-acting diuretics or
and increase cardiac
inotropic drugs (eg,
output and renal blood
dobutamine).
flow.
3. Prepare patient for
3. Provides patient with the
dialysis or continuous
opportunity to ask
renal replacement
questions and prepare
therapy if indicated.
for the procedure.
NURSING DIAGNOSIS:
Ineffective thermoregulation related to infection or
postpericardiotomy syndrome
GOAL:
Maintenance of normal body temperature
Nursing Interventions
Rationale
Expected Outcomes
1. Assess temperature
every hour.
1. Fever can indicate
infectious or
● Normal body
temperature.
inflammatory process.
2. Use aseptic technique
when changing
2. Decreases risk of
infection.
dressings, suctioning
● Incisions are free of
infection and are
healing.
● Absence of symptoms
endotracheal tube;
maintain closed systems
of postpericardiotomy
for all intravenous and
syndrome: fever,
arterial lines and for
malaise, pericardial
indwelling urinary
effusion, pericardial
catheter.
friction rub, arthralgia.
3. Observe for symptoms
3. Occurs in approximately
of postpericardiotomy
10% of patients after
syndrome.
cardiac surgery.
4. Obtain cultures and
other lab work (CBC,
4. Antibiotics treat
documented infection.
ESR); administer
antibiotics as
prescribed.
5. Administer antiinflammatory agents as
directed.
5. Relieve symptoms of
inflammation.
NURSING DIAGNOSIS:
GOAL:
Deficient knowledge about self-care activities
Ability to perform self-care activities
Nursing Interventions
Rationale
Expected Outcomes
1. Develop teaching plan
1. Each patient will have
● Patient and family
for patient and family.
unique learning needs.
members explain and
Provide specific
comply with therapeutic
instructions for the
regimen.
● Patient and family
following:
● Diet and daily
members identify
weights
necessary lifestyle
● Activity progression
changes.
● Exercise
● Has copy of discharge
● Deep breathing,
instructions (in the
coughing, lung
patient’s primary
expansion exercises
language and at
● Temperature
appropriate reading
monitoring
level; has an alternate
● Medication regimen
format if indicated).
● Pulse taking
● Keeps follow-up
● Access to the
appointments.
emergency medical
system
2. Provide verbal and
2. Repetition promotes
written instructions;
learning by allowing for
provide several teaching
questions and
sessions for
clarification of
reinforcement and
misinformation.
answering questions.
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
4. Arrangements for
information for surgeon
contacts with health
and cardiologist and
care personnel help to
instructions about
allay anxieties.
follow-up visit with
surgeon.
5. Make appropriate
5. Learning, recovery and
referrals: home care
lifestyle changes
agency, cardiac
continue after discharge
rehabilitation program,
from the hospital.
community support
groups.