Page 644 - Cardiac Nursing

6/3
0/2
6/3
0
0
0/2
1
7:4
1
009
009
0
5-6
22.
5-6
59
59
22.
xd
xd
q
q
q
A
p
A
20
A
p
ara
ara
t
p
t
20
Pa
Pa
5
7:4
5
Pa
e 6
e 6
g
g
g
K34
LWB
25_
0-c
LWBK340-c25_
LWB K34 0-c 25_ p p pp595-622.qxd 06/30/2009 17:45 Page 620 Aptara
620 PA R T I V / Pathophysiology and Management of Heart Disease
easy) to 12 to 14 (somewhat hard), to 15 to 20 (very, very diffi- patient has undergone cardiac surgery, many diagnoses used for
cult). Patients are instructed to continue their exertion until they the cardiac surgical patient can be used with the transplant recip-
perceive their exercise has become somewhat hard. 89 Patients are ient. Nursing Care Plan 25-1 is an outline of a nursing manage-
also counseled to decrease their duration of exercise if they expe- ment plan for an uncomplicated cardiac transplantation recipient.
rience excessive fatigue during or after exercise. Sample nursing diagnoses are presented. Not all possibilities have
Corticosteroid therapy, cyclosporine, and tacrolimus are detri- been discussed. Other diagnoses that the nurse may assess for in-
mental to bone density and structure. Potential corticosteroid-in- clude the following:
duced osteoporosis puts the patient in greater jeopardy of bone
■ Potential fluid volume excess related to sodium and water re-
fractures. Several types of medications are available to treat trans- tention from corticosteroid therapy
plantation osteoporosis such as bisphosphonates, calcitonin, es-
■ Potential altered nutrition: more than body requirement related
trogen, and vitamin D. Bisphosphonates, such as alendronate, in- to appetite increase from corticosteroid therapy
hibit bone resorption and can prevent bone loss. Calcitonin is
■ Potential fear or anxiety related to the possibility of rejection
another antiresorptive drug. Estrogen therapy effectively prevents and death from complications
bone loss related to estrogen deficiency. 91,92
■ Altered family processes related to disruption of family life from
Regular exercise programs help patients to control weight and prolonged hospitalization and need to reside in the local area
to minimize calcium loss from bone. Approximately 86% of for 2 to 3 months after discharge
transplant recipients are considered to have class I New York
■ Potential for noncompliance related to the complexity of the
Heart Association functional status. More than 90% of the recip- prescribed medical regime
ients report having no activity limitations up to 5 years posttrans-
plant. 77 They are capable of performing most recreational activi-
ties and are advised against contact sports or other sports with R EFERENCES
high risk of injury, such as alpine skiing, unless the recipient was 1. Diodato Jr., M. D., Maniar, H. S., Prasad, S. M., et al. (2003). Robotics
previously accomplished in the sport. Physician approval is rec- in cardiac surgery. In K. L. Franco & E. D. Verrier (Eds.), Advanced ther-
ommended if patients wish to pursue vigorous running or jog- apy in cardiac surgery (pp. 102–114). Hamilton, Ontario: BC Decker.
ging. The additional benefit of improved collateral circulation is 2. Kulier, A., Levin, J. Moser, R., et al. (2007). Impact of preoperative ane-
mia on outcome in patients undergoing coronary artery bypass graft sur-
important if chronic rejection develops at a later time. gery. Circulation, 116, 471–479.
6
6
3. McKhann, G. M., Grega, M. A., Borowicz, L. M. et al. (2006). Stroke and
7
encephalopathy after cardiac surgery an update. Stroke, 37, 562–571.
7
Preparation for Discharge 4. Ferraris, V. A., Ferraris, S. E., Moliterno, D. J., et al. (2005). The society
of thoracic surgeons practice guideline series: Aspirin and other an-
Patient preparation for discharge begins in the intensive care unit tiplatelet agents during operative coronary revascularization (executive
and continues until discharge, which can be as early as 7 days. It summary). Annals of Thoracic Surgery, 79, 1454–1461.
is important that patients fully understand their condition and the 5. Jones, H. U., Muhlestein, J. B., Jones, K. W., Bair, T. L., et al. (2002). Pre-
implications of cardiac denervation. They need to adapt to a new operative use of enoxaparin compared with unfractionated heparin in-
creases the incidence of re-exploration for postoperative bleeding after
medical regime and must understand its importance in maintain- open-heart surgery in patients who present with an acute coronary syn-
ing their state of health. Patients are discharged with multiple drome. Circulation, 106(Suppl. I), I-19–I-22.
6
6
medications and must understand their purpose, actions, and side 6. Falk, V., Jacobs, S., Walther, T., et al. (2003). Total endoscopic bypass
effects. This understanding is facilitated by a patient medication grafting. In K. L. Franco & E. D. Verrier (Eds.), Advanced therapy in car-
diac surgery (pp. 119–123). Hamilton, Ontario: BC Decker.
self-administration list that is easily interpreted, followed, and 7. Seifert, P. C. (2002a). Basic cardiac surgical procedures. In P. C. Seifert,
changeable. Many variations are available online and can be trans- Cardiac surgery: Perioperative patient care (pp. 213–257). St Louis: Mosby.
lated to several languages. By discharge, it is important that they 8.Bojar, R. M. (1999). Intraoperative considerations in cardiac surgery. In R.
assume total responsibility for self-care. Bedside flow sheets can be M. Bojar & K. G. Warner, Manual of perioperative care in cardiac surgery
(3rd ed., pp. 93–106). Malden: Blackwell Science.
used by the nursing staff to indicate the progress of the patient’s 9.Ng, C. S. H., Wan, S., Yim, A. P. C., et al. (2002). Pulmonary dysfunc-
learning. Patients are taught how to detect signs of infection and tion after cardiac surgery. Chest, 121(4), 1269–1277.
to monitor their temperature. Cardiac risk factors should be eval- 10. Eagle, K. A., Guyton, R. A., Davidoff, R., et al. (2004). ACC/AHA guide-
uated with the patient so that strategies can be outlined to de- line update for coronary artery bypass graft surgery: Summary article: A re-
crease risk. In addition to the primary nurse, dietitians, social port of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines (Committee to update the 1999 guide-
workers, physical therapists, and the nurse transplantation coordi- lines for coronary bypass surgery). Circulation, 110, 1168–1176.
nators can all contribute to patient instruction. It is important for 11. Hannan, E. L., Wu, C., Walford, G., et al. (2008). Drug-eluting stents vs.
a nurse to have good teaching skills, sensitivity to the patient’s psy- coronary artery bypass grafting in multivessel coronary disease. New Eng-
chological needs, and an ability to communicate. These skills can land Journal of Medicine, 358, 331–341.
greatly enhance the patient’s success in learning. 12. Topkara, V. K., Cheema, F. H., Kesavaramanujam, S., et al. (2005) Circu-
lation, 114(Suppl. I), I-344–I-350.
13. Seifert, P. C. (2002b). Surgery for coronary artery disease. In P. C. Seifert,
Cardiac surgery: Perioperative patient care (pp. 258–306). St Louis: Mosby.
Nursing Management Plan 14. Acorda, R., Kraus, T., & Casey, P. E. (2000). Advances in surgical treat-
ment of coronary artery disease. Nursing Clinics of North America, 35,
Nursing care of the transplant recipient is, for the most part, in- 913–932.
terdependent with medical management. The exception to this is 15. Chatterjee, K. (1998). Recognition and management of patients with sta-
the provision of patient teaching. Nonetheless, several nursing di- ble angina pectoris. In L. Goldman & E. Brauwnwald (Eds.), Primary car-
diology (pp. 234–256). Philadelphia: WB Saunders.
agnoses can be identified for the patient after cardiac transplanta- 16. Guru, V., Fremes, S. E., and Tu, J. V. (2004). Time-related mortality for
tion. This management plan focuses on diagnoses, goals, and in- women after coronary artery bypass graft surgery: A population-based
terventions unique to the transplant recipient. Because this study. Journal Thoracic and Cardiovascular Surgery, 127, 1158–1165.
7
7