Postoperative Heart Valve Replacement

PNCI® - Learner

Sina Cheffer
Age: 79
Weight: 100 kg
Location: Telemetry Unit/Rehabilitation Unit

Background
Patient History
Past Medical History: Coronary artery disease, hypertension, chronic heart failure, chronic bronchitis and
obesity. Status post aortic valve replacement with porcine valve and CABG x 1 two days ago

Allergies: No known allergies

Medications: Albuterol, atrovent, baby aspirin, furosemide, enalapril, potassium and carvedilol

Code Status: Full code

Social/Family History: Married with one adult daughter. Her husband and daughter are staying at a
motel near the hospital and their phone number is on the chart. Her daughter is a nurse who teaches
in a college nursing program. The patient’s husband was recently discharged from this same unit
following defibrillator/pacemaker placement. The daughter is managing his recovery at the motel

Handoff Report
Situation:
This patient is a 79-year-old female admitted to the Telemetry Unit post aortic valve replacement
with a porcine valve and CABG x 1. She ambulates with physical therapy twice a day in her room
but desaturates to 83 to 85% and becomes very short of breath. She gets nebulizer treatments with
albuterol and atrovent every six hours or as needed (prn). Her last treatment was at midnight. She
continues to need a lot of help with activities of daily living (ADLs) such a toileting in the bedside
commode.

Background:
She has a long history of coronary artery disease, hypertension, chronic heart failure, chronic bronchitis
and obesity. She underwent a planned aortic valve replacement and CABG x 1 two days ago. Her
post-surgical recovery in the Intensive Care Unit (ICU) was uneventful and she was transferred to the
Telemetry Unit earlier this morning.

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Handoff Report Continued

Assessment:
Vital signs: HR 95, BP 172/78, RR 38, SpO2 has been 92% on oxygen at 6 LPM via nasal cannula,
Temperature 37.5C
Cardiovascular: Sinus rhythm/sinus tachycardia with occasional PVCs
Respiratory: Breath sounds exhibit wheezing; She has oxygen at 6 LPM via nasal cannula. Becomes
short of breath on exertion and desaturates to 83 to 85% while ambulating with Physical Therapy in her
room; Her last nebulizer treatment was six hours ago
GI: Active bowel sounds. Good appetite; 2 gram sodium cardiac diet
GU: Voids spontaneously without problems. Uses bedside commode. Urine is clear and yellow
Extremities: Ambulates with Physical Therapy twice a day in her room and needs a lot of help to
transfer to the bedside commode and back to bed. Sequential compression devices are in place
Skin: Warm, dry and pink with adequate turgor. Mid-sternal chest incision and left lower leg incision
covered with dry dressing. No signs and symptoms of infection.
Neurological: Awake, alert and oriented to person, place and time. Pupils equal, round, reactive to light
and accommodation. No neurological deficits
IVs: 20-gauge IV in the right forearm, patent and non-reddened; Heparin infusing at 1000 units/hour
and 0.9% Sodium Chloride infusing at 10 mL/hour
Labs: PTT, PT, INR, CBC, electrolytes, BUN and creatinine this morning. Results pending
Fall Risk: High risk
Pain: Denies pain

Recommendations:
Perform a complete assessment and monitor for any acute changes.

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Orders
Initial Healthcare Provider’s Orders:
Admit to Telemetry Unit
Diagnosis: Status post aortic valve replacement and CABG x 1
Full code
2 gram sodium cardiac diet
Bedside commode
Physical therapy to ambulate patient twice a day
Vital signs every 4 hours
Notify the healthcare provider for premature ventricular contractions greater than 5 per minute,
coupling, multifocal, bigeminy, or ventricular tachycardia
Continuous telemetry and SpO2 monitoring
Oxygen at 6 LPM via nasal cannula
Clean incisions with antiseptic skin cleanser and dress daily and PRN to keep dry
Sequential compression devices while in bed
Albuterol 0.5% solution 0.5 mL (2.5 mg) via nebulizer every 6 hours while awake and PRN
Atrovent 0.02% solution 2.5 mL (0.5 mg) via nebulizer every 6 hours while awake and PRN
Sliding scale heparin drip per protocol
NS at 10 mL/hour to keep vein open
Enteric coated aspirin 81 mg PO every day
Furosemide 40 mg PO every AM
Enalapril maleate 2.5 mg PO every AM
Potassium 20 mEq PO every day
Carvedilol 3.125 mg PO twice a day
Warfarin 5 mg PO every day at 1700
Docusate 100 mg PO every day
Ascorbic acid 1000 mg PO every day
Magnesium hydroxide 30 mL PO PRN
Amiodarone 400 mg PO three times per day
CBC, electrolytes, magnesium, BUN, creatinine, PT, PTT and INR daily

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Preparation
Learning Objectives
• States the precautions needed for anticoagulation therapy in a person with mechanical valve
replacement (REMEMBERING)
• Uses history information and assessment data to prioritize, individualize and provide care for a
person who develops respiratory distress (APPLYING)
• Anticipates diagnostic orders and therapies, including medications, for the person with an acute
gastrointestinal bleed as a complication of anticoagulation therapy (UNDERSTANDING)
• Implements healthcare provider’s orders correctly as directed (APPLYING)
• Analyzes the event history, assessment findings and lab values to anticipate and treat
complications of acute gastrointestinal bleed and urinary tract infection (ANALYZING)

Recommended eDose modules for learners to complete before the SCE:

Medication Dosage Calculation Skills
X Medication Orders & S. I. Units
X Tablets & Capsules
Liquid Medicines
X Injections
X I.V. Infusions
Injectable Medicines Therapy
X Slow I.V. Injections
Intermittent Infusions
X Continuous Infusions
Pediatrics

This SCE addresses the following QSEN Competencies:

X Patient-Centered Care
X Teamwork and Collaboration
X Evidence-Based Practice
X Quality Improvement
X Safety
Informatics

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Preparation Questions
• What assessment findings might the nurse identify in a patient experiencing acute respiratory
distress?
• What does SpO2 mean? What is the normal value?
• Identify at least three major complications following aortic valve replacement and the
collaborative management to avoid these complications.
• What laboratory test results would be monitored in a patient who is bleeding and why?
• What vital sign changes would be expected in a patient who is bleeding and why?
• What are the required nursing interventions when administering blood or blood products to a
patient?
• What are the signs and symptoms associated with a blood transfusion reaction?
• What are the signs and symptoms associated with a deep vein thrombosis?
• Why are sequential compression devices (SCDs) used on patients? How often and how long should
they be removed?
• Name at least three patient safety teaching points when administering anticoagulants to a patient.
• Answer the following questions related to the HIPAA guidelines:
oo Which individuals may review a patient’s medical record?
oo Who may receive information about a patient’s condition?
oo What information may be given to others about a patient’s condition?
• What are the pharmacokinetics of amiodarone and warfarin?

References
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(9th ed.). St. Louis, MO: Elsevier Mosby.

Bonow, R.O., Carabello, B.A., Chatterjee, K., de Leon, Jr., A.C., Faxon, D.P, Freed, M.D., … Shaw, P.M.
(2008). 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of
Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for
the Management of Patients With Valvular Heart Disease). Journal of the American College of Cardiology,
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Domino, F.J., Baldor, R.A., Golding, J., Grimes, J.A., & Taylor, J.S. (Eds.).(2009). The 5-Minute Clinical Consult
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Dunning, J., Versteegh, M., Fabbri, A., Pavie, A., Kolh, P., Lockowandt, U., & Nashef, S. A. M. (2008).
Guideline on antiplatelet and anticoagulation management in cardiac surgery. European Journal of
Cardio-Thoracic Surgery, 34(1), 73-92. doi: 10.1016/j.ejcts.2008.02.024

Edelman, C.L., & Mandle, C.L. (2010). Health promotion throughout the life span (7th ed.). St. Louis, MO:
Mosby Elsevier.

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References Continued
Forehand, M. (2010). Bloom’s taxonomy: Emerging perspectives on learning, teaching, and technology.
Department of Educational Psychology and Instructional Technology, University of Georgia. Retrieved
from http://projects.coe.uga.edu/epltt/index.php?title=Bloom%27s_Taxonomy

Giger, J.N., & Davidhizar, R.E. (2008). Transcultural nursing: Assessment and intervention (5th ed.). St. Louis,
MO: Mosby Elsevier.

Holcomb, S.S. (2009). An update on antithrombotic guidelines. The Nurse Practitioner, 34(1), pp. 6-10.
doi:10.1016/j.ccell.2007.07.004

Hughes, S., & Messerly, S. (2009). Patient education: A critical component in caring for patients on
warfarin. Journal of Cardiovascular Nursing, 24(2), 171-173. doi: 10.1097/JCN.0b013e318197b5c5

Johnson-Russell, J. (2010). Facilitated debriefing. In W.M. Nehring & F.R. Lashely (Eds.), High fidelity
patient simulation in nursing education, pp. 369-385. Sudbury, MA: Jones and Bartlett.

Lewis, S.L., Dirkse, S.R., Heitkemper, M.M., & Bucher, L. (2011). Medical-surgical nursing: Assessment and
management of clinical problems (8th ed.). St. Louis, MO: Elsevier Mosby.

Lockwood, C., Conroy-Hiller, T., & Page, T. (2004). Vital signs. International Journal of Evidence-Based
Healthcare, 2(6), 207-230. doi:10.1111/j.1479-6988.2004.00012.x

Melnyk, B.M., & Fineout-Overholt, E. (2010). Evidence-based practice in nursing & healthcare: A guide to
best practice (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

National Council of State Boards of Nursing (2010). 2010 NCLEX-RN test plan. Retrieved July 6, 2011, from
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from http://www.qsen.org/competencies.php

Ridge, R.A., & Antonacci, L.M. (2008). Shining a spotlight on anticoagulation safety. Nursing, 38(8), 22-23.
doi:10.1097/01.NURSE.0000327479.09581.d6

Salem, D. N., O’Gara, P. T., Madias, C., Pauker, S. G., & American College of Chest Physicians. (2008).
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The Joint Commission. (2012). National patient safety goals. Retrieved January 26, 2012 from http://
www.jointcommission.org/standards_information/npsgs.aspx

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References Continued
Vahanian, A., Baumgartner, H., Bax, J., Butchart, E., Dion, R., Filippatos, G., … ESC Committee for Practice
Guidelines. (2007). Guidelines on the management of valvular heart disease: The task force on the
management of valvular heart disease of the European Society of Cardiology. European Heart Journal,
28(2), 230-268. doi:10.1093/eurheartj/ehl428

Van Damme, S., Van Deyk, K., Budts, W., Verhamme, P., & Moons, P. (2011). Patient knowledge of and
adherence to oral anticoagulation therapy after mechanical heart-valve replacement for congenital or
acquired valve defects. Heart & Lung: The Journal of Acute and Critical Care, 40(2), 139-146. doi:10.1016/j.
hrtlng.2009.11.005

Authors
Neil Fried, Kathy Herrin and Margaret Peters, Texas Woman’s University - Dallas, TX. Reviewed by Neil
Fried, Texas Woman’s University - Dallas, TX and Christie Schrotberger, Diane Mathe, Lynde Rabine,
Gwen Leigh and Donna Walls, CAE Healthcare - Sarasota, FL, 2012

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© 2012 CAE Healthcare, Sarasota, FL v.5