Page 165 - Critical Care Nursing Demystified

150 CRITICAL CARE NURSING DeMYSTIFIED

Plan for early intubation within 4 hours to decrease the chance of ventilator-
assisted pneumonia.
Perform PA, CVP, PCWP, CO, and CI as per hospital protocol to determine
if the patient is hemodynamically stable.
Assess urinary output every hour to determine if CO and fluid status is ad-
equate, and also to see if renal status is impaired. The patient should have at
least 30 cc/hr. The physician should be notified if this standard has not been
met to prevent dehydration and early renal failure.
Measure chest tube output every hour until stable to determine if there is
cardiac tamponade or hemorrhage. Observe surgeon’s protocol for abnormal
drainage, usually more than 100 mL/hr.
Monitor cardiac rhythm status as elderly patients can go into atrial fibrilla-
tion and may need to be treated with antiarrhythmic medications, antico-
agulation, or cardioversion; PVCs are also frequent signs of ventricular
irritability (see Chapter 4, Care of the Patient with Critical Cardiac Rhythm
Disturbance Needs).
Rewarm (slowly) the patient if needed with warming blankets, by increas-
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which can lead to dysrhythmias, hypoxemia, and impaired coagulation.
Observe for pulmonary edema as a result of increased capillary permeability
that occurs with third spacing after surgery.
Observe for PE and DVT as the patient is on bedrest and clots can be a
complication of IABP, CP bypass, bedrest, and atrial dysrhythmias.
Monitor neurologic status using the Glasgow Coma Scale as patients are at
increased risk for stroke. (see Chapter 5, Care of the Patient with Neuro-
logical Needs).

Assess bowel sounds as patients will have absent sounds initially, but they
will return within a day of getting out of bed (OOB).

Monitor oral gastric tube and administer antiulcer medications to prevent
stress ulcers.

Monitor IABP if patient needs counterpulsation to give the heart a rest after
surgery.

Administer a hypertonic solution like D51/4NSS to reabsorb third-space
fluids.

Have patient turn, cough, and deep breathe and administer percussion and
incentive spirometry (when extubated) to prevent atelectasis and pulmonary
infections.