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:

1. 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.

2. Mobility Encouragement:

   • Step-by-Step Approach: Encourage mobility within physical limitations.
   • Educational Efforts: Provide information on safe exercises post-surgery.

3. 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.

4. Vital Signs Monitoring:

   • Step-by-Step Approach: Monitor vital signs as ordered.
   • Monitoring Strategies: Regular vital sign checks and documentation.

5. 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.

6. Edema Monitoring:

   • Step-by-Step Approach: Monitor for edema and notify MD if present.
   • Technological Aids: Use compression stockings if ordered.

7. Oxygen Therapy:

   • Step-by-Step Approach: Administer supplemental oxygen as needed and/or as ordered.
   • Technological Aids: Use oxygen delivery devices as prescribed.

8. Pain Management:

   • Step-by-Step Approach: Medicate for pain and intervene per pain care plan.
   • Technological Aids: Use pain assessment tools.

9. Blood Glucose Monitoring:

   • Step-by-Step Approach: Monitor blood glucose levels as indicated.
   • Technological Aids: Use glucometers.

10. 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.

11. Follow-Up Care:

    • Step-by-Step Approach: Ensure follow-up visits with the cardiac surgeon as ordered.
    • Educational Efforts: Provide reminders and educational materials.

12. 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.

13. Diet Compliance:

    • Step-by-Step Approach: Provide diet as ordered and encourage compliance.
    • Educational Efforts: Offer dietary education and consults as needed.

14. 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:

1. 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.

2. Mobility Encouragement:

   • Staff will encourage mobility within physical limitations.

3. Leg Elevation:

   • Staff will encourage keeping feet elevated when at rest to promote venous return.

4. Vital Signs Monitoring:

   • Staff will monitor vital signs as ordered.

5. Lung Sounds Monitoring:

   • Staff will monitor lung sounds as ordered and notify MD with any development of adventitious lung sounds.

6. Edema Monitoring:

   • Staff will monitor for edema and notify MD if present.

7. Oxygen Therapy:

   • Staff will administer supplemental oxygen as needed and/or as ordered.

8. Pain Management:

   • Staff will medicate for pain and intervene per pain care plan.

9. Blood Glucose Monitoring:

   • Staff will monitor blood glucose levels as indicated.

10. Lab Work:

    • Staff will draw labs as ordered, monitor results, and report to attending physician.

11. Follow-Up Care:

    • Staff will ensure follow-up visits with the cardiac surgeon as ordered.

12. Sternal Precautions:

    • I will follow sternal precautions: no pulling, pushing, or lifting; no bed trapeze for the period specified by the cardiac surgeon.

13. Diet Compliance:

    • Staff will provide diet as ordered and encourage compliance.

14. Cardiac Medications:

    • Staff will administer cardiac medications as ordered and intervene per cardiac care plan.