S/P Cardiac Surgery
Care Plan for S/P Cardiac Surgery
Category / Primary Body System:
Cardiovascular
Problem:
I am at risk for complications and infection due to recent cardiac surgery.
Goal:
My incision will heal without signs or symptoms of infection within 90 days.
Plan/Approach:
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Incision Monitoring:
- Step-by-Step Approach: Monitor the incision every shift for signs of infection, including redness, warmth, swelling, purulent drainage, and fever. Notify MD with any noted signs of infection.
- Monitoring Strategies: Use a standardized infection assessment tool.
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Mobility Encouragement:
- Step-by-Step Approach: Encourage mobility within physical limitations.
- Educational Efforts: Provide information on safe exercises post-surgery.
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Leg Elevation:
- Step-by-Step Approach: Encourage keeping feet elevated when at rest to promote venous return.
- Technological Aids: Use pillows or leg wedges for elevation.
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Vital Signs Monitoring:
- Step-by-Step Approach: Monitor vital signs as ordered.
- Monitoring Strategies: Regular vital sign checks and documentation.
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Lung Sounds Monitoring:
- Step-by-Step Approach: Monitor lung sounds as ordered and notify MD with any development of adventitious lung sounds.
- Monitoring Strategies: Regular auscultation and documentation.
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Edema Monitoring:
- Step-by-Step Approach: Monitor for edema and notify MD if present.
- Technological Aids: Use compression stockings if ordered.
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Oxygen Therapy:
- Step-by-Step Approach: Administer supplemental oxygen as needed and/or as ordered.
- Technological Aids: Use oxygen delivery devices as prescribed.
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Pain Management:
- Step-by-Step Approach: Medicate for pain and intervene per pain care plan.
- Technological Aids: Use pain assessment tools.
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Blood Glucose Monitoring:
- Step-by-Step Approach: Monitor blood glucose levels as indicated.
- Technological Aids: Use glucometers.
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Lab Work:
- Step-by-Step Approach: Draw labs as ordered, monitor results, and report to attending physician.
- Monitoring Strategies: Timely collection and analysis of lab results.
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Follow-Up Care:
- Step-by-Step Approach: Ensure follow-up visits with the cardiac surgeon as ordered.
- Educational Efforts: Provide reminders and educational materials.
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Sternal Precautions:
- Step-by-Step Approach: Follow sternal precautions: no pulling, pushing, or lifting; no bed trapeze for the period specified by the cardiac surgeon.
- Educational Efforts: Educate the patient on the importance of sternal precautions.
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Diet Compliance:
- Step-by-Step Approach: Provide diet as ordered and encourage compliance.
- Educational Efforts: Offer dietary education and consults as needed.
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Cardiac Medications:
- Step-by-Step Approach: Administer cardiac medications as ordered and intervene per cardiac care plan.
- Monitoring Strategies: Monitor for side effects and efficacy.
Rationale:
- Incision Monitoring: Early detection of infection ensures prompt treatment and prevents complications.
- Mobility Encouragement: Safe mobility reduces the risk of blood clots and promotes overall recovery.
- Leg Elevation: Elevation helps reduce swelling and promotes venous return.
- Vital Signs Monitoring: Regular monitoring detects early signs of complications.
- Lung Sounds Monitoring: Early detection of respiratory complications allows for prompt intervention.
- Edema Monitoring: Monitoring and managing edema prevents further complications.
- Oxygen Therapy: Ensures adequate oxygenation, promoting healing and comfort.
- Pain Management: Effective pain control enhances recovery and mobility.
- Blood Glucose Monitoring: Helps in managing blood sugar levels, especially important in surgical recovery.
- Lab Work: Timely lab results guide treatment decisions.
- Follow-Up Care: Regular follow-up ensures ongoing monitoring and management of recovery.
- Sternal Precautions: Protect the surgical site and promote healing.
- Diet Compliance: Proper nutrition supports recovery and overall health.
- Cardiac Medications: Ensures optimal cardiac function and prevents complications.
Actions:
-
Incision Monitoring:
- Staff will monitor the incision every shift for signs of infection, including redness, warmth, swelling, purulent drainage, and fever. Notify MD with any noted signs of infection.
-
Mobility Encouragement:
- Staff will encourage mobility within physical limitations.
-
Leg Elevation:
- Staff will encourage keeping feet elevated when at rest to promote venous return.
-
Vital Signs Monitoring:
- Staff will monitor vital signs as ordered.
-
Lung Sounds Monitoring:
- Staff will monitor lung sounds as ordered and notify MD with any development of adventitious lung sounds.
-
Edema Monitoring:
- Staff will monitor for edema and notify MD if present.
-
Oxygen Therapy:
- Staff will administer supplemental oxygen as needed and/or as ordered.
-
Pain Management:
- Staff will medicate for pain and intervene per pain care plan.
-
Blood Glucose Monitoring:
- Staff will monitor blood glucose levels as indicated.
-
Lab Work:
- Staff will draw labs as ordered, monitor results, and report to attending physician.
-
Follow-Up Care:
- Staff will ensure follow-up visits with the cardiac surgeon as ordered.
-
Sternal Precautions:
- I will follow sternal precautions: no pulling, pushing, or lifting; no bed trapeze for the period specified by the cardiac surgeon.
-
Diet Compliance:
- Staff will provide diet as ordered and encourage compliance.
-
Cardiac Medications:
- Staff will administer cardiac medications as ordered and intervene per cardiac care plan.
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