CARDIAC SURGERY: POSTOPERATIVE CARE—CORONARY ARTERY BYPASS GRAFT (CABG), MINIMALLY

INVASIVE DIRECT CORONARY ARTERY BYPASS (MIDCAB), CARDIOMYOPLASTY, VALVE REPLACEMENT

NURSING DIAGNOSIS: risk for decreased Cardiac Output Risk Factors

May Include Altered contractility recent Altered preload—hypovolemia; altered afterload—systemic

vascular resistance Altered heart rate/rhythm

Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual
diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Tissue Perfusion: Cardiac Display hemodynamic stability, such as stable blood pressure, cardiac
output. Report and display decreased episodes of angina and dysrhythmias. Demonstrate an
increase in activity tolerance. Participate in activities that maximize and enhance cardiac function.

NURSING DIAGNOSIS: acute Pain

May Be Related To
Injuring physical agents—surgical incisions, tissue inflammation, edema formation, intraoperative nerve trauma
Possibly Evidenced By
Verbal/coded reports of pain
Guarding behavior
Expressive behaviors—restlessness, irritability
Changes in heart rate, blood pressure, respiratory rate
Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Verbalize relief or absence of pain.
Demonstrate relaxed body posture and ability to rest and sleep appropriately.
Pain Control
Differentiate surgical discomfort from angina or preoperative heart pain.

NURSING DIAGNOSIS: risk for ineffective Breathing Pattern

Risk Factors May Include
Pain
Musculoskeletal impairment
Possibly Evidenced By
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Ventilation
Maintain an effective respiratory pattern free of cyanosis and other signs and symptoms of hypoxia, with breath sounds equal
bilaterally, lung fields clearing.
Display complete reexpansion of lungs with absence of pneumothorax and hemothorax.
NURSING DIAGNOSIS: impaired Skin/Tissue Integrity
May Be Related To
Mechanical factors (e.g., surgery)
Possibly Evidenced By
Disruption of skin surface/damaged tissue [surgical incisions, puncture wounds]
Desired Outcomes/Evaluation Criteria—Client Will
Wound Healing: Primary Intention
Demonstrate behaviors and techniques to promote healing and prevent complications.
Display timely wound healing.

NURSING DIAGNOSIS: deficient Knowledge [Learning Need] regarding condition,

postoperative care, self-care, and discharge needs
May Be Related To
Lack of exposure or recall
Information misinterpretation
Possibly Evidenced By
Reports the problem
Inaccurate follow-through of instructions
Desired Outcomes/Evaluation Criteria—Client Will
Self-Management: Cardiac Disease
Participate in learning process.
Assume responsibility for own learning.
Begin to ask questions and look for information.
Knowledge: Treatment Regimen
Verbalize understanding of condition, prognosis, and potential complications.

THROMBOPHLEBITIS: VENOUS
THROMBOEMBOLISM (INCLUDING
PULMONARY EMBOLI CONSIDERATIONS)

NURSING DIAGNOSIS: ineffective peripheral tissue Perfusion

May Be Related To
Deficient knowledge of aggravating factors—sedentary lifestyle/immobility, trauma, smoking, obesity
Possibly Evidenced By
Edema, extremity pain
Diminished pulses, capillary refill >3 seconds
Altered skin characteristics—color, temperature
Desired Outcomes/Evaluation Criteria—Client Will
Tissue Perfusion: Peripheral
Demonstrate improved perfusion as evidenced by peripheral pulses present, equal skin color, and temperature normal and
absence of edema.
Engage in behaviors or actions to enhance tissue perfusion.
Display increasing tolerance to activity.

NURSING DIAGNOSIS: acute Pain

May Be Related To
Injury agent—physical (inflammatory process); chemical (accumulation of lactic acid in tissues)
Possibly Evidenced By
Reports pain
Guarding behavior
Expressive behaviors—restlessness
Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Report that pain or discomfort is alleviated or controlled.
Verbalize methods that provide relief.
Display relaxed manner; be able to sleep or rest and engage in desired activity.

NURSING DIAGNOSIS: impaired Gas Exchange (in presence of Pulmonary

Embolus)
May Be Related To
Ventilation-perfusion imbalance [altered blood flow to alveoli or to major portions of the lung]
Alveolar-capillary membrane changes
Possibly Evidenced By
Dyspnea, restlessness, [apprehension], somnolence
Abnormal arterial blood gases, hypoxemia, hypercapnia
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Gas Exchange
Demonstrate adequate ventilation and oxygenation by ABGs within client’s normal range.
Report or display resolution or absence of symptoms of respiratory distress.

NURSING DIAGNOSIS: deficientKnowledge [Learning Need] regarding condition,

treatment program, self-care, and discharge needs
May Be Related To
Lack of exposure or recall
Misinterpretation of information
Unfamiliarity with information resources
Possibly Evidenced By
Reports the problem
Inaccurate follow-through of instructions
Desired Outcomes/Evaluation Criteria—Client Will
Knowledge: Thrombus Prevention
Verbalize understanding of disease process, treatment regimen, and limitations.
Participate in learning process.
Identify signs and symptoms requiring medical evaluation.
Correctly perform therapeutic actions and explain reasons for actions.

COPD

NURSING DIAGNOSIS: ineffective Airway Clearance

May Be Related To
Chronic obstructive pulmonary disease
Airway spasm, allergic airways
Excessive mucus, retained secretions, exudates in the alveoli
Smoking/secondhand smoke
Possibly Evidenced By
Dyspnea, difficulty vocalizing
Changes in depth and rate of respirations
Diminished/adventitious breath [wheezes, rhonchi, crackles]
Absent/ineffective cough
Restlessness, cyanosis
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Airway Patency
Maintain patent airway with breath sounds clear or clearing.
Demonstrate behaviors to improve airway clearance.

NURSING DIAGNOSIS: impaired Gas Exchange

May Be Related To
Ventilation-perfusion imbalance [retained secretions, bronchospasm, air-trapping]
Alveolar-capillary membrane changes
Possibly Evidenced By
Dyspnea
Confusion, restlessness
Abnormal breathing (e.g., rate, rhythm, depth); tachycardia
Abnormal ABGs—hypoxia, hypercapnia
Nasal flaring; abnormal skin color (e.g., pale, dusky)
Reduced tolerance for activity
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Gas Exchange
Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within client’s normal range and be free
of symptoms of respiratory distress.
Participate in treatment regimen within level of ability and situation.

NURSING DIAGNOSIS: imbalanced Nutrition: less than body requirements

May Be Related To
Biological factors—dyspnea; medication side effects; anorexia, nausea or vomiting; fatigue
Possibly Evidenced By
Body weight 20% or more under ideal; poor muscle tone
Reported altered taste sensation, aversion to eating, lack of interest in food
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Display progressive weight gain toward goal as appropriate.
Demonstrate behaviors and lifestyle changes to regain and maintain appropriate weight

NURSING DIAGNOSIS: ineffective Self-Health Management

May Be Related To
Deficient knowledge; complexity of therapeutic regimen
Economic difficulties
Perceived benefits/seriousness
Possibly Evidenced By
Reports difficulty with prescribed regimen
Failure to include treatment regimens in daily living
Failure to take action to reduce risk factors

Self-Management: Chronic Obstructive Pulmonary Disease/Asthma Management

Verbalize understanding of condition and disease process and treatment.
Identify relationship of current signs and symptoms to the disease process and correlate these with causative factors.
Initiate necessary lifestyle changes and participate in treatment regimen.

HEART FAILURE: CHRONIC

NURSING DIAGNOSIS: decreased Cardiac Output
May Be Related To
Altered contractility (such as valvular defects and ventricular aneurysm)
Altered heart rate, rhythm
Altered afterload (vascular resistence)
Possibly Evidenced By
Tachycardia, arrhythmias, ECG changes
Variations in blood pressure readings (hypotension, hypertension)
Decreased peripheral pulses
S3, S4 heart sounds
Orthopnea, crackles, jugular vein distension, edema, weight gain
Skin color changes, clammy skin
Oliguria
Desired Outcomes/Evaluation Criteria—Client Will
Cardiac Pump Effectiveness
Display vital signs within acceptable limits, dysrhythmias absent or controlled, and no symptoms of failure, for example,
hemodynamic parameters within acceptable limits and urinary output adequate.
Report decreased episodes of dyspnea and angina.
Cardiac Disease Self-Management
Participate in activities that reduce cardiac workload.

NURSING DIAGNOSIS: Activity Intolerance

May Be Related To
Imbalance between oxygen supply and demand
Generalized weakness
Sedentary lifestyle
Possibly Evidenced By
Reports fatigue, feeling weak
Abnormal blood pressure/heart rate in response to activity
Exertional dyspnea
Desired Outcomes/Evaluation Criteria—Client Will
Endurance
Participate in desired activities; meet own self-care needs.
Achieve measurable increase in activity tolerance, evidenced by reduced fatigue and weakness and by vital signs within
acceptable
limits during activity.

NURSING DIAGNOSIS: excess Fluid Volume

May Be Related To
Compromised regulatory mechanism (reduced glomerular filtration rate, increased antidiuretic hormone [ADH] production, and
sodium and water retention)
Excess sodium intake
Possibly Evidenced By
Orthopnea, S3 heart sound
Oliguria, edema, JVD, positive hepatojugular reflex
Weight gain over short period of time
Blood pressure changes
Pulmonary congestion, adventitious breath sounds
Desired Outcomes/Evaluation Criteria—Client Will
Fluid Overload Severity
Demonstrate stabilized fluid volume with balanced intake and output, breath sounds clear or clearing, vital signs within
acceptable
range, stable weight, and absence of edema.
Verbalize understanding of individual dietary and fluid restrictions.

NURSING DIAGNOSIS: risk for impaired Gas Exchange

Risk Factors May Include
Alveolar-capillary membrane changes such as fluid collection and shifts into interstitial space or alveoli
Possibly Evidenced By
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Gas Exchange
Demonstrate adequate ventilation and oxygenation of tissues by ABG values and oximetry within client’s normal ranges and be
free of symptoms of respiratory distress.
Participate in treatment regimen within level of ability and situation.

NURSING DIAGNOSIS: risk for chronic Pain

Risk Factors May Include
Chronic physical disease or condition
Altered ability to continue previous activities
Possibly Evidenced By
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Verbalize and demonstrate relief or control of pain or discomfort.
Demonstrate and initiate behavioral modifications of lifestyle and appropriate use of therapeutic interventions

NURSING DIAGNOSIS: risk for Impaired Skin Integrity

Risk Factors May Include
Impaired circulation
Possibly Evidenced By
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Tissue Perfusion: Peripheral
Maintain skin integrity.
Demonstrate behaviors or techniques to prevent skin breakdown.

NURSING DIAGNOSIS: ineffective Self-Health Management

May Be Related To
Complexity of therapeutic regimen
Perceived seriousness/susceptibility
Deficient knowledge
Economic difficulties
Possibly Evidenced By
Reports difficulty with prescribed regimen
Failure to include treatment regimen in daily living
Failure to take action to reduce risk factors
Unexpected acceleration of illness symptoms
Desired Outcomes/Evaluation Criteria—Client Will
Self-Management: Heart Failure
Identify relationship of ongoing therapies (treatment program) to reduction of recurrent episodes and prevention of
complications.
List signs and symptoms that require immediate intervention.
Identify own stress and risk factors and some techniques for handling them.
Initiate necessary lifestyle and behavioral changes.