Page 640 - Cardiac Nursing

LWBK340-c25_p595-622.qxd 06/30/2009 17:45 Page 616 Aptara

616 PA R T IV / Pathophysiology and Management of Heart Disease

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Nursing Care Plan 25-1 Th Thee PPatientt wiith Unccommplliccatedd Carrddiac Trannspllaanntationn
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Nursing Diagnosis 1 ➧ Decreased cardiac output in the immediate postoperative period related to cardiac denervation
and ischemia during transplantation, manifested by bradycardia and hypotension.
Nursing Goal 1 ➧ To detect early manifestations of decreased cardiac output.
Outcome Criteria ➧ 1. Patient will maintain a mean arterial blood pressure (MAP) between 70 and 90 mm Hg.
2. Patient will maintain a sinus rhythm with a heart rate (HR) of 100 to 110 beats/min.
3. Changes in above conditions will be detected within 20 minutes of occurrence.
4. Patient’s skin will be warm, dry, and normal in color.
5. Nail beds will return to normal color after blanching from pressure over the capillary bed.
6. All peripheral pulses will be palpable. Urine output will be 30 mL/h.
7. Changes in 4, 5, and 6 above will be detected within an hour of occurrence.
NURSING INTERVENTIONS RATIONALE
1. Assess and document MAP, HR, and rhythm continuously. 1. Required to detect changes.
2. Report any HR 100, loss of sinus rhythm, or MAP 2. An HR 100 may be considered bradycardic for the imme-
70 mm Hg to physician. diate postoperative transplantation period and may indi-
cate the need for more isoproterenol support. Myocardial
edema and manipulation of the heart during surgery
increase the risk of bradycardia. Junctional rhythms occur
at lesser degrees of bradycardia in the transplant recipient
and loss of sinus rhythm may indicate the need for atrial
pacing. Loss of blood pressure may be a result of
bradycardia or loss of sinus rhythm.
3. Evaluate volume status; a central venous pressure (CVP) 3. Hypotension also may be an indication of hypovolemia or
8 mm Hg may indicate need for fluid. If MAP 60 mm Hg a depressed inotropic state related to ischemia incurred
with an adequate CVP, hypotension may be a result of de- during surgery and organ donation. Further evaluation is
creased contractility. Notify physician if these findings occur. required.
4. Assess and document skin temperature, color, moisture, 4. Low cardiac output will be manifested by decreased
capillary filling, quality of peripheral pulses, and urine peripheral perfusion and decreased renal vascular blood
output hourly as needed. Report abnormal findings to flow, resulting in decreased glomerular filtration and
physician. subsequent urine output.
Nursing Goal 2 ➧ To reduce or eliminate manifestations of decreased cardiac output specifically bradycardia or
hypotension
Outcome Criteria ➧ 1. Within 15 minutes of intervention, HR returns to 100 beats/min.
2. Within 15 minutes of intervention, MAP returns to 70 mm Hg.
3. Within 30 minutes of intervention, good peripheral pulses are present, skin is warm, dry,
and of normal color.
NURSING INTERVENTIONS RATIONALE
1. Connect pacing wires to a temporary pacemaker. Obtain 1. Temporary pacing may be indicated to maintain an HR in
an order for pacing support and appropriate settings. HR the prescribed parameters.
is usually maintained at 100 beats/min minimum.
2. Notify physician if a junctional rhythm develops and 2. Sinus node function may be impaired due to myocardial
results in bradycardia or hypotension. edema in the area of the sinus node. Atrial pacing may be
indicated.
3. Verify that CVP is between 8 and 12 mm Hg and administer 3. Hypotension may be the result of hypovolemia: a
ordered replacement fluid if CVP is below ordered denervated heart depends on a large stroke volume to
minimum (usually 8 mm Hg). stretch myocardial fibers (Starling mechanism) and
produce a strong contraction.
4. Notify physician if hypotension does not respond to 4. Hypotension may be the result of decreased contractility,
volume therapy or is present with an adequate CVP. and further inotropic support is needed.