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CABG concept map

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by

Brian Bracher

on 26 February 2013

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Transcript of CABG concept map

Patient History Current smoker with 15-20 pack year history.
History of prior MI 2002; angioplasty 2002.
Patient is a full code Primary Medical Diagnosis Coronary Artery Disease: arteriosclerosis involving accumulation of fatty plaque within the walls of the coronary arteries that supply the myocardium with oxygen and nutrients. The deposition of the plaque in the lumen of an artery causes narrowing of lumen of the artery by decreasing its diameter. CAD often causes angina, myocardial ischemia, and myocardial infarction. (Lemone, 2011) Secondary Medical Diagnoses Myocardial infarction: Death of a region of the myocardium caused by an interruption in the supply of blood (ergo oxygen and nutrients) to the heart, usually as a result of occlusion of a coronary artery. (Lemone, 2011)

Angina - A condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by ischemia (inadequate oxygenated blood supply) to the heart. Stable angina has a predictable trigger whereas unstable angina is not tied to any trigger and can occur spontaneously. Angina is generally due to obstruction or spasm of the coronary arteries. The main cause of Angina is CAD, due to atherosclerosis of the arteries supplying blood to the heart. (Lemone, 2011)

Hypertension – A chronic condition in which the blood pressure is elevated, requiring the heart to work harder than normal to circulate blood through the blood vessels. High blood pressure is said to be present if it is persistently at or above 140/90 mmHg. (Lemone, 2011)

Diabetes mellitus Type II - insulin resistance with an insulin secretory deficit. The diagnosis of diabetes mellitus is based on either fasting plasma glucose levels or the results of glucose tolerance testing and is supported by clinical manifestations. A major factor of the development of DM is cellular resistance to the effect of insulin. This resistance is increased by obesity, inactivity, illnesses, medications, and increasing age.” (Venes, Biderman, & Fenton, 2009) Assessment Objective data Subjective data BP: 141/79 Temp: 98'F RR: 22 Heartrate: 79
Alert & oriented x3
Pupils are PERRLA
Pain is a 1 on 1-10 scale
Patient appears restless
Skin is warm and dry
10cm Sternal incision and 5cm leg incision wound are well approximated with no redness
Bilateral chest tube incision wounds are not red
Pulses are +2 in both right and left radial and dorsalis pedis Cap refill is <3sec Heart sounds heard are s1 & s2Normal sinus heart rhythm
Breath sounds heard are slight crackles on inspiration; bases diminished;
IV site is an internal jugular PICC on right side
Abdomen is soft and nontender
Bowel sounds are present but hypoactive in all 4 quadrants
Patient has a foley catheter with an 8 hours output of 1200ml clear/yellow urine Patient verbalized discomfort from chest tubes Diagnostic Studies 1/22 – ECG – abnormal; findings suggested myocardial infarction
1/22 – Heart catheterization – findings of multivessel disease Treatments Bilateral Chest Tubes: Drainage of fluid from pleural space
Dressing change: Promote healing & discourage infection
Incentive Spirometry: Help keep expansion and elasticity of alveoli
Nasal cannula O2: Keep blood oxygen levels high to ensure oxygenation of myocardium Diet Cardiac diet: Fat and Sodium restrictions of a cardiac diet help by not contributing to the narrowing of coronary arteries. Impaired comfort r/t chest tube placement AEB patient stating the chest tubes were causing her discomfort and she "couldn't wait to get them out." General Goal Behavioral Outcome Objective Patient will display timely wound healing Patient will demonstrate behaviors & techniques to promote healing & prevent complications. Labs Key Data Patient presented to Lehigh Regional at approximately 2am on 1/22 with severe chest pain at rest & hypertension. ECG results were abnormal, suggesting an inferior myocardial infarction. Patient was immediately transported to GCMC for a heart catheterization where she was found to have multivessel occlusion (occlusion present in the LAD, the posterior lateral obtuse marginal branch of the circumflex, and in the posterior descending branch of the RCA). Patient was then scheduled for coronary artery bypass graft. Leading to admission Impaired skin/tissue integrity r/t 10cm sternal incision, 5cm leg incision, & chest tubes bilaterally AEB disruption to skin and underlying tissue as a result of coronary artery bypass surgery #1 Nursing Diagnosis #2 Nursing Diagnosis #3 Nursing Diagnosis Ineffective Health Maintenance r/t smoking and poor diet AEB patient reporting she "smokes 1/2 to 1 pack of cigarettes per day" and "eats a diet high in fat and salt" even though she knew it would "make her heart problems worse." Psychosocial General Goal Patient will verbalize relief from discomfort. Behavioral Outcome Objective Patient will demonstrate relaxed body posture and ability to rest. General Goal Behavioral Outcome Objective Patient will assume responsibility for own healthcare needs within level of ability. Patient will adopt lifestyle changes supporting individual healthcare goals. Interventions Evaluation Interventions Interventions Evaluation Evaluation Nurse will inspect incisions and evaluate healing process (Lemone 2011 p.78)
Nurse will change dressing, using aseptic technique, as indicated by physician. (Lemone 2011 p.78)
Nurse will review with patient normal signs of healing, such as itching along wound line, bruising, slight redness, and scabbing. (Doenges 2010 p.108)
Nurse will have client shower in warm water, washing incisions gently.Instruct client to avoid tub baths until approved by physician.(Doenges 2010 p.108)
Nurse will suggest wearing soft cotton shirts and loose-fitting clothing,leaving incisions open to air as much as possible, covering, and padding portion of incisions as necessary. (Doenges 2010 p.108)
Nurse will help to maintain patient's hydration and nutritional status. (Doenges 2010 p.109) Incisions are healing by primary intention. Wound edges well approximated. No redness or discharge. Cool and dry.
Dressing changed; silverlon on chest incision reused as per doctor order.
After explanation, patient was able to restate normal signs of healing.
Patient understands she is to avoid tub baths until wound is fully healed.
Patient open to wearing loose-fitting clothes and leaving wounds open to air to facilitate healing.
Over 6 hours patient drank 600ml of water and consumed >80% of her breakfast. She also was able to verbalize the importance of hydration and nutrition in the healing process. Nurse will monitor vital signs. (Doenges 2010 p.106)
Nurse will observe for anxiety, irritability, crying, restlessness, and sleep disturbances. (Doenges 2010 p.106)
Nurse will identify and promote position of comfort, using adjuncts as necessary. (Doenges 2010 p.106)
Nurse will medicate before procedures and activities, as indicated. (Doenges 2010 p.106)
Nurse will administer medications for pain and discomfort as prescribed by physician (Doenges 2010 p.107 & Lemone 2011 p.80)
Nurse will remove chest tubes as indicated by physician. Nurse will review modifiable and nonmodifiable risk factors of heart disease. (Lemone 2011 pp.912-913, 919-920)
Nurse will review importance of cessation of smoking, weight control,dietary changes, and exercise. (Doenges 2010 p.76)
Note patient's desire and level of ability to meet health maintenance needs.(Doenges 2010 p.903)
Nurse will refer to support services for smoking cessation. (Doenges 2010 p.818 & Lemone 2011 p.919)
Nurse will help the patient identify specific sources of psychosocial and physical support for smoking cessation, dietary, and lifestyle changes (Lemone 2011 p.920) Vital signs stable: BP: 141/79 Temp: 98'F RR: 22 Heartrate: 79
Patient appears restless and anxious (twitching legs, clenching hands, rapid respirations). Patient verbalized that the discomfort of the chest tubes are making her anxious.
Assisted patient to find a comfortable position in bed.
Administered pain medication to patient, as ordered, before removal of chest tubes.
The verbalized source of patient's discomfort, the chest tubes, were removed by nurse.
After removal of chest tubes, patient verbalized a relief in comfort and was able to relax comfortably in bed. Reviewed modifiable and nonmodifiable risk factors with patient. Verbalized understanding of things able to be changed.
Reviewed importance of smoking cessation and dietary changes with patient. Verbalized understanding, Stated that maybe now she can do it.
Patient does not seem excited to make lifestyle changes but verbalized a willingness to try to do so, even though past attempts have failed.
Patient spoke with a cardiac rehab nurse and received information about available smoking cessation programs.
Requested a consult from a dietician to come speak with the patient about easy ways to prepare and eat a heart healthy diet.
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