NURSING MANAGEMENT

IDEAL

 Nursing Diagnosis:
 Impaired gas exchange related to pulmonary congestion
 Nursing interventions:
 Note respiratory rate, depth; accessory muscles, pursed-lip breathing; note areas of pallor/cyanosis
 Auscultate breath sounds, note areas of adventitious sounds as well as fremitus.
 Monitor vital signs and cardiac rhythm.
 Evaluate pulse oximetry to determine oxygenation.
 Elevate HOB, perform suctioning as indicated to maintain airway.
 Provide supplemental oxygen at lowest concentration indicated by laboratory results and client symptoms or situation.
 Maintain adequate I/O for mobilization of secretions but avoid fluid overload.
 Encourage adequate rest and limit activities within client tolerance to help limit oxygen needs/consumption.
 Administer medications as indicated to treat underlying conditions.

 Nursing Diagnosis:
 Decreased cardiac output related to compromised myocardial infarction
 Nursing Interventions:
 Assess and monitor vital signs.
 Keep patient on bed rest or provide adequate rest periods.
 Provide relaxation technique.
 Elevate lower extremities.
 Administer medications as ordered.
 Administer oxygen as indicated.
 Monitor/adjust ventilator settings as indicated when mechanical support is being used.

 Nursing Diagnosis:
 Ineffective tissue perfusion related to decreased peripheral blood flow
 Nursing Interventions:
  Note presence/degree of dyspnea, presence of dysrhythmias.
 Monitor vital signs, hemodynamics, heart sounds, and cardiac rhythm.
 Encourage quiet, restful atmosphere to conserve energy and to lower tissue oxygen demands.
 Caution client to avoid activities that increase cardiac workload.
 Administer medications as prescribed.
 Encourage use of relaxation techniques to decrease tension level.

 Nursing Diagnosis:
 Activity intolerance related to decreased cardiac output
 Nursing interventions:
 Monitor vital signs, watching for changes in blood pressure, heart, and respiratory rate.
 Plan care with rest periods between activities to reduce fatigue.
 Encourage expression of feelings contributing to/resulting from condition.
 Promote comfort measures and provide for relief of pain to enhance ability to participate in activities.

ACTUAL

Day 1 (October 30, 2018)  Checked and regulated IVF.

 Performed assessment.  Provided bedside care.
 Checked and monitored vital signs hourly.  Provided NGT feeding.
 Performed suctioning.  Checked and monitored IVF.
 Monitored intake and output.  Monitored intake and output.
 Administered medications as prescribed.  Performed suctioning.
 Observed characteristics of secretions.
Day 2 (October 31, 2018)  Provided NGT feeding.
 Provided bedside care.  Provided PROM exercise.
 Checked and monitored vital signs hourly.  Administered medications as ordered.
 Checked and monitored IVF.  Performed backtapping.
 Monitored intake and output.  Repositioned every two (2) hours.
 Performed suctioning.
 Observed characteristics of secretions. Day 4 (November 02, 2018)
 Provided NGT feeding.  Provided bedside care.
 Provided PROM exercise.  Checked and monitored vital signs hourly.
 Administered medications as ordered.  Checked and monitored IVF.
 Performed backtapping.  Monitored mechanical ventilator and cardiac monitor.
 Repositioned every two (2) hours.  Monitored intake and output.
 Performed suctioning.
 Observed characteristics of secretions.
 Provided NGT feeding.
 Provided PROM exercise.
 Administered salbutamol via nebulizer.
Day 3 (November 01, 2018)  Administered medications as ordered.
 Provided bedside care.  Repositioned every two (2) hours.
 Checked and monitored vital signs hourly.

SURGICAL MANAGEMENT
IDEAL


 Valve replacement – surgical replacement of stenotic or incompetent valves with a mechanical or bioprosthetic valve.
 General anesthesia and cardiopulmonary bypass are used for valve replacements. Performed through a median sternotomy (incision through the sternum), although
mitral valve may be approached through a right thoracotomy incision. Mitral, and more rarely aortic, valve replacements may be performed with minimally invasive
techniques that do not involve cutting through the length of the sternum. Instead incisions are made in only the upper or lower half of the sternum or between ribs;
these incisions are only 2 to 4 inches long. Some of these minimally invasive procedures are robot assisted; the surgical instruments are connected to a robot, and the
surgeon, watching a video display, uses a joystick to control the robot and surgical instruments. After valve is visualized, the leaflets of the aortic or pulmonic valve are
removed, but some of the mitral valve structures (leaflets, chordate, and papillary muscles) are left inplace to help maintain the shape and function of the left ventricle
after mitral valve replacement. Sutures are placed around the annulus and then through the valve prosthesis. The replacement valve is slid down the suture into position
and tied into place. The incision is closed, and the surgeon evaluates the function of the heart and the quality of the prosthetic repair. The patient is weaned from
cardiopulmonary bypass, the surgical repair is often assessed with color flow Doppler TEE, and the surgery is completed.

 Preoperative nursing interventions:

 Complete patient and family preoperative teaching
 Determine patient’s understanding of the procedure
 Describe the operating room, PACU, and preoperative and postoperative routines
 Demonstrate the postoperative turning, coughing, deep breathing, splinting, and range-of-motion (ROM) exercises
 Explain the postoperative need for drainage tube, surgical dressings, oxygen therapy, I.V. therapy, and pain control
 Allay the patient’s and family’s anxiety about surgery
 Document the patient’s history and physical assessment data base
 Obtain baseline hemodynamic variables ECG readings, and ABG studies
 Complete a preoperative checklist
 Administer preoperative medications

 Postoperative nursing interventions:

 Assess vital signs every 5 to 15 minutes and as needed until patient recovers from anesthesia or sedation, and then is assessed every 2 to 4 hours and as needed.
 Administer IV medications to increase or decrease blood pressure and to treat dysrhythmias or altered heart rates and monitor medications effects.
 Patient assessments are conducted every 1 to 4 hours as needed, with particular attention to neurologic, respiratory, and cardiovascular systems.
 Administer oxygen and maintain an endotracheal (ET) tube to ventilator
 Monitor vital signs, intake and output (I/O), laboratory studies, ECG, hemodynamic variables, daily weight, and pulse oximetry
  Monitor and maintain the water seal chest drainage system for mediastinal and pleural chest tubes
 Monitor and maintain the position and patency of drainage tubes and catheters such as nasogastric tube, indwelling catheter, and wound drainage and chest
tubes
 Administer I.V. fluids and transfusion therapy, as prescribed
 Inspect and change the surgical dressing, as ordered
 Keep the patient in semi-fowler’s position
 Provide incentive spirometry after extubation or ET suction
 Reinforce turning, coughing, and deep breathing, and splinting of the incision
 Administer antiarrhythmics, anticoagulants, vasopressors, beta adrenergic blockers, diuretics, or cardiac glycosides, as prescribed
 Monitor the patient for arrhythmias
 Check peripheral circulation: color, temperature, pulses, and complaints of abnormal sensations, such as numbness or tingling
 Insulate epicardial pacing wires; have temporary pacemaker available
 Administer antibiotics, as prescribed
 Assess for return of peristalsis
 Provide the prescribed diet, as tolerated
 Assist the patient with active and passive ROM and isometric exercises, as tolerated
 Allay the patient’s anxiety

ACTUAL

 None