Professional Documents
Culture Documents
1. Reassure patient that you 1. Fear that pain will not be Reports relief that pain is
know pain accepted as accepted as
is real and will assist him or her real increases tension and real and that he or she will
in anxiety receive assistance
dealing with it. and decreases pain tolerance. in pain relief
2. Use pain assessment scale to 2. A pain assessment scale • Reports lower intensity of
identify provides pain and
intensity of pain. baseline for assessing changes discomfort after interventions
3. Assess and record pain and in implemented
its characteristics: pain level and evaluating • Reports less disruption from
intensity, location, quality, interventions. pain and
frequency, and duration. 3. Data assist in evaluating pain discomfort after use of
4. Administer balanced and intervention
analgesic pain relief and identifying • Uses pain medication as
agents as prescribed to multiple prescribed
promote sources and types of pain. • Identifies effective pain relief
optimal pain relief. 4. Analgesic agents are more strategies
5. Readminister pain effective • Demonstrates use of new
assessment scale. if administered early in the pain strategies
6. Document severity of cycle. Simultaneous use of to relieve pain and reports their
patient’s pain analgesic effectiveness
on chart. agents that work on different • Experiences minimal side
7. Obtain additional portions effects of
prescriptions as of the nociceptive system will analgesia without interruption
needed. provide greater pain relief with to treat
8. Identify and encourage fewer side effects
patient to side effects. • Increases interactions with
use strategies that have been 5. This permits assessment of family and
successful effectiveness friends
with previous pain. of analgesia and identifies
9. Teach patient additional need for further action if
strategies to ineffective.
relieve pain and discomfort: 6. This assists in demonstrating
distraction, the
relaxation, cutaneous need for additional analgesic
stimulation, agents
etc. or alternative approach to pain
management.
10. Instruct patient and family 7. Inadequate pain relief results
about potential in an
side effects of analgesic increased stress response,
agents and their prevention and suffering,
management. and prolonged hospitalizations.
8. This encourages use of pain
relief
strategies familiar to and
accepted
by patient.
9. Use of these strategies along
with
analgesia may produce more
effective
pain relief.
10. Anticipating and preventing
side effects
enable the patient to continue
analgesia without interruption
because
of side effects
NURSING DIAGNOSIS: Decreased cardiac output related to blood loss and compromised myocardial
function
GOAL: Restoration of cardiac output to maintain organ and tissue perfusion
3.
Car
diac
tam
pon
ade
resu
lts
fro
m
blee
ding
into
the
peri
car
dial
sac
or
acc
um
ulat
ion
of
flui
d in
the
sac,
whi
ch
com
pres
ses
the
hea
rt
and
pre
ven
ts
ade
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te
fillin
g of
the
ven
tricl
es.
Dec
reas
e in
che
st
drai
nag
e
may
indi
cate
that
flui
d
and
clot
s
are
acc
um
ulat
ing
in
the
peri
car
dial
sac.
4.
Car
diac
fail
ure
resu
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fro
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dec
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pu
mpi
ng
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on
of
the
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can
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se
defi
cien
t
perf
usio
n to
vital
org
ans.
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 1. Adequate circulating blood • Normal blood pressure with
balance. volume is position
a. Accurately document intake necessary for optimal cellular changes.
and activity; • Absence of dysrhythmia.
output; record urine volume fluid and electrolyte imbalance • Stable weight.
every can occur after surgery. • Arterial blood pH 7.35 to 7.45.
half hour to 4 hours while in a. Provides a method to • Serum potassium 3.5 to 5.0
critical determine mEq/L
care unit; then every 8 to 12 positive or negative fluid (3.5 to 5.0 mmol/L).
hours while hospitalized balance • Serum magnesium 1.3 to 2.3
and fluid requirements. mg/dL
b. Assess blood pressure, (0.62 to 0.95 mmol/L).
hemodynamic b. Provides information about • Serum sodium 135 to 145
parameters, weight, state mEq/L (135
electrolytes, of hydration. to 145 mmol/L).
hematocrit, jugular c. Excessive blood loss from • Serum calcium 8.6 to 10.2
venous pressure, breath chest mg/dL
sounds, cavity can cause hypovolemia. (2.15 to 2.55 mmol/L).
urinary output, and nasogastric d. Indicator of fluid balance. • Serum glucose less than 110
tube drainage. 2. A specific concentration of mg/dL.
c. Measure postoperative chest electrolytes
drainage; cessation of drainage is necessary in both
may indicate kinked or blocked extracellular
chest tube. Ensure patency and and intracellular body fluids to
integrity of the drainage sustain life.
system. a. Causes: inadequate intake,
Maintain autotransfusion diuretics,
system vomiting, excessive nasogastric
if in use. drainage, stress from surgery.
d. Weigh daily and correlate b. Causes: increased intake,
with intake hemolysis
and output. from cardiopulmonary bypass/
2. Be alert to changes in serum mechanical assist devices,
electrolyte acidosis, renal insufficiency. The
levels.
a. Hypokalemia (low potassium) resin binds potassium and
Effects: dysrhythmias: PVCs, promotes
ventricular intestinal excretion of it. IV
tachycardia. Observe for sodium bicarbonate drives
specific ECG changes. potassium
Administer into the cells from extracellular
IV potassium replacement as fluid. Insulin assists the cells
prescribed. with glucose and potassium
b. Hyperkalemia (high absorption.
potassium) c. Low levels of magnesium are
Effects: ECG changes, tall associated
peaked with dysrhythmias, muscle
T waves, wide QRS, spasm, and tetany. Low levels
brachycardia. of sodium are associated with
Be prepared to administer weakness and neurological
diuretic symptoms.
or an ion-exchange resin Low levels of calcium can
(sodium polystyrene sulfonate lead to dysrhythmias and
[Kayexalate]); IV sodium muscle
bicarbonate, spasm.
or IV insulin and glucose. d. Cause: stress response to
c. Monitor serum magnesium, surgery.
sodium and calcium. Affects both patients with
d. Hyperglycemia (high blood diabetes and those without
glucose) diabetes.
Effects: increased urine
output, thirst, metabolic
acidosis
Administer insulin as
prescribed.
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 • Urine output consistent with
a. Measure urine output every deficient fluid intake;
half perfusion, hemolysis, low greater than 30 mL/h.
hour to 4 hours in critical care cardiac • Urine specific gravity 1.003 to
then every 8 to 12 hours until output, and use of vasopressor 1.030.
hospital discharge.
b. Monitor and report lab agents to increase blood • BUN, creatinine, electrolytes
results: pressure. within
BUN, serum creatinine, serum a. Less than 30 mL/h indicates normal limits.
electrolytes. decreased
2. Prepare to administer rapid- renal function.
acting diuretics b. Indicate kidneys’ ability to
or inotropic drugs (eg, excrete
dobutamine). waste products.
3. Prepare patient for dialysis or 2. Promote renal function and
continuous increase
renal replacement therapy if cardiac output and renal blood
indicated. flow.
3. Provides patient with the
opportunity
to ask questions and prepare
for the
procedure.
1. Develop teaching plan for 1. Each patient will have unique • Patient and family members
patient learning explain
and family. Provide specific needs. and comply with therapeutic
instructions 2. Repetition promotes learning regimen.
for the following: by allowing • Patient and family members
• Diet and daily weights for questions and clarification identify
• Activity progression of misinformation. necessary lifestyle changes.
• Exercise 3. Family members responsible • Has copy of discharge
• Deep breathing, coughing, for instructions (in
lung home care are usually anxious the patient’s primary language
expansion exercises and and at
• Temperature monitoring require adequate time for appropriate reading level; has
• Medication regimen learning. an alternate
• Pulse taking 4. Arrangements for contacts format if indicated).
• Access to the emergency with • Keeps follow-up
medical health care personnel help to appointments.
system allay
2. Provide verbal and written anxieties.
instructions; 5. Learning, recovery and
provide several teaching lifestyle
sessions
for reinforcement and changes continue after
answering questions. discharge
3. Involve family in teaching from the hospital.
sessions.
4. Provide contact information
for surgeon
and cardiologist and
instructions
about follow-up visit with
surgeon.
5. Make appropriate referrals:
home
care agency, cardiac
rehabilitation
program, community support
groups.