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Nursing Diagnosis:
Nursing Diagnosis:
Impaired gas exchange related to pulmonary
congestion Decreased cardiac output related to compromised
Nursing interventions:
myocardial infarction

Note respiratory rate, depth; accessory muscles, Nursing Interventions:

pursed-lip breathing; note areas of pallor/cyanosis
Assess and monitor vital signs.
Auscultate breath sounds, note areas of adventitious
sounds as well as fremitus.
Keep patient on bed rest or provide adequate rest
Monitor vital signs and cardiac rhythm.
Provide relaxation technique.
Evaluate pulse oximetry to determine oxygenation.
Elevate lower extremities.
Elevate HOB, perform suctioning as indicated to
maintain airway. Administer medications as ordered.
Provide supplemental oxygen at lowest concentration Administer oxygen as indicated.
indicated by laboratory results and client symptoms
or situation. Monitor/adjust ventilator settings as indicated when
Maintain adequate I/O for mobilization of secretions
mechanical support is being used.
but avoid fluid overload.
Encourage adequate rest and limit activities within
client tolerance to help limit oxygen
Administer medications as indicated to treat
underlying conditions.
Nursing Diagnosis: Nursing Diagnosis:
Ineffective tissue perfusion related to decreased Activity intolerance related to decreased cardiac
peripheral blood flow output
Nursing Interventions: Nursing interventions:
Note presence/degree of dyspnea, presence of Monitor vital signs, watching for changes in blood
dysrhythmias. pressure, heart, and respiratory rate.
Monitor vital signs, hemodynamics, heart sounds, Plan care with rest periods between activities to
and cardiac rhythm. reduce fatigue.
Encourage quiet, restful atmosphere to conserve Encourage expression of feelings contributing
energy and to lower tissue oxygen demands. to/resulting from condition.
Caution client to avoid activities that increase Promote comfort measures and provide for relief
cardiac workload. of pain to enhance ability to participate in
Administer medications as prescribed. activities.

Encourage use of relaxation techniques to

decrease tension level.
Day 2 (October 31, 2018)
Provided bedside care.
Checked and monitored vital
Day 1 (October 30, 2018)
signs hourly.
Performed assessment.
Checked and monitored IVF.
Checked and monitored vital signs hourly.
Monitored intake and output.
Checked and regulated IVF.
Performed suctioning.
Provided bedside care.
Observed characteristics of
Provided NGT feeding.
Performed suctioning.
Provided NGT feeding.
Monitored intake and output.
Provided PROM exercise.
Administered medications as prescribed.
Administered medications as
Performed backtapping.
Repositioned every two (2)
Day 4 (November 02, 2018)
Day 3 (November 01, 2018) Provided bedside care.
Provided bedside care. Checked and monitored vital signs
Checked and monitored vital signs hourly.
hourly. Checked and monitored IVF.
Checked and monitored IVF. Monitored mechanical ventilator
Monitored intake and output. and cardiac monitor.
Performed suctioning. Monitored intake and output.
Observed characteristics of Performed suctioning.
secretions. Observed characteristics of
Provided NGT feeding. secretions.
Provided PROM exercise. Provided NGT feeding.
Administered medications as Provided PROM exercise.
ordered. Administered salbutamol via
Performed backtapping. nebulizer.
Repositioned every two (2) hours. Administered medications as
Repositioned every two (2) hours.

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)
 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

 None