NURSING DIAGNOSIS: Pain

GOAL: Relief of pain or decrease in intensity of pain

Nursing Interventions Rationale Expected Outcomes

1. Reassure patient that you
know pain
is real and will assist him or her
in
dealing with it.
2. Use pain assessment scale to
identify
intensity of pain.
3. Assess and record pain and
its characteristics:
intensity, location, quality,
frequency, and duration.
4. Administer balanced
analgesic
agents as prescribed to
promote
optimal pain relief.
5. Readminister pain
assessment scale.
6. Document severity of
patient’s pain
on chart.
7. Obtain additional
prescriptions as
needed.
8. Identify and encourage
patient to
use strategies that have been
successful
with previous pain.
9. Teach patient additional
strategies to
relieve pain and discomfort:
distraction,
relaxation, cutaneous
stimulation,
etc.
1. Fear that pain will not be Reports relief that pain is
accepted as accepted as
real increases tension and real and that he or she will
anxiety receive assistance
and decreases pain tolerance. in pain relief
2. A pain assessment scale • Reports lower intensity of
provides pain and
baseline for assessing changes discomfort after interventions
in implemented
pain level and evaluating • Reports less disruption from
interventions. pain and
3. Data assist in evaluating pain discomfort after use of
and intervention
pain relief and identifying • Uses pain medication as
multiple prescribed
sources and types of pain. • Identifies effective pain relief
4. Analgesic agents are more strategies
effective • Demonstrates use of new
if administered early in the pain strategies
cycle. Simultaneous use of to relieve pain and reports their
analgesic effectiveness
agents that work on different • Experiences minimal side
portions effects of
of the nociceptive system will analgesia without interruption
provide greater pain relief with to treat
fewer side effects
side effects. • Increases interactions with
5. This permits assessment of family and
effectiveness friends
of analgesia and identifies
need for further action if
ineffective.
6. This assists in demonstrating
the
need for additional analgesic
agents
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

Nursing Interventions Rati Exp

onal ect
e ed
Ou
tco
me
s
1. Monitor cardiovascular status. Serial 1. •
readings of blood pressure, other hemodynamic Effe Th
parameters, and cardiac ctiv e
rhythm and rate are obtained, ene foll
recorded, and correlated with the patient’s ss ow
overall condition. of ing
a. Assess arterial blood pressure car par
every 15 minutes until stable; diac am
then arterial or cuff blood pressure out ete
put rs
is are
every 1 to 4 hours det wit
erm hin
24 ine the
hours; then every 8 to 12 hours d pat
until hospital discharge. by ien
b. Auscultate for heart sounds and con t’s
rhythm. tinu nor
c. Assess peripheral pulses (pedal, ous ma
tibial, radial). mo l
d. Monitor hemodynamic parameters nito ran
to assess cardiac output, volume ring ges
status, and vascular tone. . :
e. Watch for trends in hemodynamics a. Art
and note that mechanical ventilation Blo eri
may alter hemodynamics. od al
f. Monitor ECG pattern for cardiac pres pre
dysrhythmias and ischemic sure ssu
changes. is re
g. Assess cardiac biomarker results. one CV
h. Measure urine output every half of P
hour to 1 hour at first, then with the Pul
vital signs. mos mo
i. Observe buccal mucosa, nail beds, t nar
lips, earlobes, and extremities. imp y
j. Assess skin; note temperature orta art
and color. nt ery
2. Observe for persistent bleeding: excessive phy pre
chest tube drainage of siol ssu
blood; hypotension; low CVP; tachycardia. ogic res
Prepare to administer blood par PA
products, IV solutions. am WP
eter He
s art
3. Observe for cardiac tamponade: hypotension; to sou
rising CVP and PAWP, pulsus mo nds
paradoxus; muffled heart nito Pul
sounds; weak, thready pulse; jugular r; mo
vein distention; decreasing urinary vas nar
output. Check for diminished amount oco y
of blood in chest drainage collection nstr an
system. Prepare for reoperation. ictio d
4. Observe for signs of cardiac failure. n sys
Prepare to administer diuretics, afte te
digoxin, IV inotropic agents. r mic
car vas
dio cul
pul ar
mo
nar resi
y sta
byp nce
ass Car
may dia
req c
uire out
trea put
tme an
nt d
wit car
h an dia
IV c
vas ind
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ator Per
. iph
b. era
Aus l
cult pul
atio ses
n Car
pro dia
vide c
s rat
evid e
enc an
e of d
car rhy
diac th
tam m
pon Car
ade dia
(mu c
ffle bio
d ma
dist rke
ant rs
hea Uri
rt ne
sou out
nds) put
, Ski
peri n
car an
ditis d
(pre mu
cor cos
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rub) col
, or
dysr Ski
hyt n
hmi te
as. mp
c. era
Pres tur
enc e
e or •
abs Les
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and n
qual 20
ity 0
of mL
puls /h
es of
pro dra
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as firs
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tive 6
lesi ho
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Risi •
ng Vit
CVP al
and sig
PA ns
WP sta
may ble
indi .
cate
con •
gest CV
ive P
hea an
rt d
fail oth
ure er
or he
pul mo
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nar na
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ede par
ma. am
Low ete
pres rs
sure wit
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may nor
indi ma
cate l
nee lim
d its.
for •
volu Uri
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ace out
me put
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e. hin
Tre nor
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Me ati
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intr sou
ath nds
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cic •
pres Pai
sure n
. lim
f. ite
Dys d
rhyt to
hmi inci
as sio
may n
occ
ur
wit
h
cor
ona
ry
isch
emi
a,
hyp
oxia
,
blee
ding
,
acid
-
bas
e or
elec
trol
yte
dist
urb
anc
es,
digi
talis
toxi
city,
or
car
diac
fail
ure.
ST-
seg
me
nt
cha
nge
s
may
indi
cate
my
oca
rdia
l
isch
emi
a.
Pac
em
ake
r
capt
ure
and
anti
arrh
yth
mic
me
dica
tion
s
are
use
d to
mai
ntai
n
hea
rt
rate
and
rhyt
hm
and
to
sup
port
blo
od
pres
sure
.
g.
Elev
atio
ns
may
indi
cate
my
oca
rdia
l
infa
rcti
on.
h.
Urin
e
out
put
less
tha
n
30
mL/
h
indi
cate
s
dec
reas
ed
ren
al
perf
usio
n
and
may
refl
ect
dec
reas
ed
car
diac
out
put.
i.
Dus
kine
ss
and
cya
nosi
s
may
indi
cate
dec
reas
ed
car
diac
out
put.
j.
Coo
l
moi
st
skin
indi
cate
s
vas
oco
nstr
ictio
n
and
dec
reas
ed
car
diac
out
put.
2.
Ble
edi
ng
can
resu
lt
fro
m
surg
ical
trau
ma
to
tiss
ues,
anti
coa
gula
nt
me
dica
tion
s,
and
clot
ting
def
ects

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
qua
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
lts
fro
m
dec
reas
ed
pu
mpi
ng
acti
on
of
the
hea
rt;
can
cau
se
defi
cien
t
perf
 usio
n to
vital
org
ans.

NURSING DIAGNOSIS: Impaired gas exchange related to chest surgery

GOAL: Adequate gas exchange

Nursing Interventions Rationale Expected Outcomes

1. Maintain mechanical 1. Ventilatory support is used to • Airway patent.

ventilation until
the patient is able to breathe
independently.
2. Monitor arterial blood gases,
tidal
volume, peak inspiratory
pressure,
and extubation parameters.
3. Auscultate chest for breath
sounds.
4. Sedate patient adequately, as
prescribed,
and monitor respiratory rate
and depth.
5. Suction tracheobronchial
secretions
as needed, using strict aseptic
technique.
6. Assist in weaning and
endotracheal
tube removal.
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.
decrease
work of the heart, to maintain
effective ventilation, and to
provide an
airway in the event of
complications.
2. ABGs and ventilator
parameters indicate
effectiveness of ventilator and
changes that need to be made
to improve
gas exchange.
3. Crackles indicate pulmonary
congestion;
decreased or absent breath
sounds may indicate
pneumothorax,
hemothorax, dislodgement of
tube.
4. Sedation helps the patient to
tolerate
the endotracheal tube and to
cope
with ventilatory sensations.
5. Retention of secretions leads
to hypoxia
and possible infection.
6. Extubation decreases risk of
pulmonary
infections and enhances ability
of patient to communicate.
7. Aids in keeping airway
patent, preventing
• ABGs within normal range.
• Endotracheal tube correctly
placed, as
evidenced by x-ray.
• Breath sounds clear
bilaterally.
• Ventilator synchronous with
respirations.
• Breath sounds clear after
suctioning/coughing.
• 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.
• Able to be weaned
successfully from
ventilator

NURSING DIAGNOSIS: Risk for imbalanced fluid volume and electrolyte imbalance related to
alterations in blood volume
GOAL: Fluid and electrolyte balance
Nursing Interventions
1. Monitor fluid and electrolyte
balance.
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
b. Assess blood pressure,
hemodynamic
parameters, weight,
electrolytes,
hematocrit, jugular
venous pressure, breath
sounds,
urinary output, and nasogastric
tube drainage.
c. Measure 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.
d. Weigh daily and correlate
with intake
and output.
2. Be alert to changes in serum
electrolyte
levels.
atelectasis, and facilitating
lung expansion.
Rationale Expected Outcomes
1. Adequate circulating blood • Normal blood pressure with
volume is position
necessary for optimal cellular changes.
activity; • Absence of dysrhythmia.
fluid and electrolyte imbalance • Stable weight.
can occur after surgery. • Arterial blood pH 7.35 to 7.45.
a. Provides a method to • Serum potassium 3.5 to 5.0
determine mEq/L
positive or negative fluid (3.5 to 5.0 mmol/L).
balance • Serum magnesium 1.3 to 2.3
and fluid requirements. mg/dL
(0.62 to 0.95 mmol/L).
b. Provides information about • Serum sodium 135 to 145
state mEq/L (135
of hydration. to 145 mmol/L).
c. Excessive blood loss from • Serum calcium 8.6 to 10.2
chest mg/dL
cavity can cause hypovolemia. (2.15 to 2.55 mmol/L).
d. Indicator of fluid balance. • Serum glucose less than 110
2. A specific concentration of mg/dL.
electrolytes
is necessary in both
extracellular
and intracellular body fluids to
sustain life.
a. Causes: inadequate intake,
diuretics,
vomiting, excessive nasogastric
drainage, stress from surgery.
b. Causes: increased intake,
hemolysis
from cardiopulmonary bypass/
mechanical assist devices,
acidosis, renal insufficiency. The
a. Hypokalemia (low potassium)
Effects: dysrhythmias: PVCs,
ventricular
tachycardia. Observe for
specific ECG changes.
Administer
IV potassium replacement as
prescribed.
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 glucose.
c. Monitor serum magnesium,
sodium and calcium.
d. Hyperglycemia (high blood
glucose)
Effects: increased urine
output, thirst, metabolic
acidosis
Administer insulin as
prescribed.
resin binds potassium and
promotes
intestinal excretion of it. IV
sodium bicarbonate drives
potassium
into the cells from extracellular
fluid. Insulin assists the cells
with glucose and potassium
absorption.
c. Low levels of magnesium are
associated
with dysrhythmias, muscle
spasm, and tetany. Low levels
of sodium are associated with
weakness and neurological
symptoms.
Low levels of calcium can
lead to dysrhythmias and
muscle
spasm.
d. Cause: stress response to
surgery.
Affects both patients with
diabetes and those without
diabetes.

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:
a. Measure urine output every
half
hour to 4 hours in critical care
then every 8 to 12 hours until
hospital discharge.
1. Renal injury can be caused by
deficient
perfusion, hemolysis, low
cardiac
output, and use of vasopressor
• Urine output consistent with
fluid intake;
greater than 30 mL/h.
• Urine specific gravity 1.003 to
1.030.
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.

NURSING DIAGNOSIS: Deficient knowledge about self-care activities

GOAL: Ability to perform self-care activities.

Nursing Interventions Rationale Expected Outcomes

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.

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 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.
Encourage family to visit.
e. Assess for medications that
may
contribute to delirium.
1. Postcardiotomy delirium may • Cooperates with procedures.
result • Sleeps for long, uninterrupted
from anxiety, sleep deprivation, intervals.
increased • Oriented to person, place,
sensory input, disorientation time.
to night and day. Normally, • Experiences no perceptual
sleep cycles distortions,
are at least 50 minutes long. hallucinations, disorientation,
The delusions.
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 inadequate in number.
2. Observe for perceptual
distortions,
hallucinations, disorientation,
and
paranoid delusions
2. Delirium can indicate a
serious medical
condition such as hypoxia,
acidbase
imbalance, metabolic
abnormalities, and cerebral
infarction.

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 1. Fever can indicate infectious • Normal body temperature.
hour. or inflammatory • Incisions are free of infection
2. Use aseptic technique when process. and are
changing 2. Decreases risk of infection. healing.
dressings, suctioning 3. Occurs in approximately 10% • Absence of symptoms of
endotracheal of patients postpericardiotomy
tube; maintain closed systems after cardiac surgery. syndrome: fever, malaise,
for all intravenous and arterial 4. Antibiotics treat documented pericardial effusion, pericardial
lines infection. friction
and for indwelling urinary 5. Relieve symptoms of rub, arthralgia.
catheter. inflammation.
3. Observe for symptoms of
postpericardiotomy
syndrome.
4. Obtain cultures and other lab
work
(CBC, ESR); administer
antibiotics as
prescribed.
5. Administer anti-inflammatory
agents
as directed.