Constipation
1. Characteristics: What is the frequency, consistency, color
of the stools? Is this a change in bowel habits? If a change,
has this been gradual or sudden? What is the size of the
stools? Have there been dietary changes? Is there blood or
mucus in the stools? Any laxative use?
2. Associated factors: Are there periods of diarrhea? Is
there abdominal pain or distention? Is the patient expe-
riencing stress? Is there a change in activity level? Does
the patient have a regular time for defecation? Does the
patient use antacids containing calcium or an anti-
cholinergic? Have there been any fevers, chills, night
sweats, or weight loss?
3. History: Any family history of colorectal cancer? Any
history of depression or metabolic disorders, such as
hypothyroidism or hypercalcemia?
Dysphagia
1. Characteristics: Is the onset acute or gradual? Is the prob-
lem with swallowing intermittent or continuous? Is this
associated with solid foods, liquids, or both? Has there
been any nasal regurgitation? Where does the food stick:
neck (cricopharyngeal), midesophagus, or sternal xiphoid
process?
2. Associated factors: Is there any regurgitation, heartburn,
chest or back pain, weight loss? Any hoarseness, voice
change, or sore throat? Have there been any fevers, chills,
night sweats, or weight loss?
3. History: Is there a family history of esophageal cancer?
Is there a history of stroke, palsy, or any other neuro-
logic conditions? Is there a history of alcohol or tobacco
intake?
PHYSICAL EXAMINATION
When performing a physical examination of the abdomen,
include the following: inspection of the abdomen, ausculta-
tion of all four abdominal quadrants, percussion for tympany
or dullness, light and deep palpation.
NURSING ALERT Auscultation should be performed before
percussion and palpation, which may stimulate bowel sounds.
Deep palpation in noted areas of tenderness or pain should be per-
formed last.

Avoiding Complications
1. Monitor ECG continuously for arrhythmias.
a. Evaluate possible cause of dysrhythmias—inadequate
oxygenation, electrolyte imbalance, MI, mechanical
irritation (eg, pacing wires, invasive lines, chest
tubes), and any vasopressor or inotropic medications.
b. Treat dysrhythmias immediately because they may
lead to decreased CO. Atrial or AV pacing is used to
treat sinus bradycardia or junctional rhythm with
heart rates less than 70 beats/minute.
2. Assess for signs of cardiac tamponade—arterial hypoten-
sion; rising CVP; rising left atrial pressure; muffled heart
sounds; weak, thready pulse; jugular vein distention;
falling urine output.
a. Check for diminished amount of drainage in the
chest-collection bottle; may indicate that fluid is accu-
mulating elsewhere.
b. Prepare for pericardiocentesis.
c. Assist with echocardiogram to evaluate tamponade.
3. Check cardiac enzyme levels daily. Elevations may indi-
cate MI. (Symptoms may be masked by the usual postop-
erative discomfort.)
a. Watch for decreased CO in the presence of normal
circulating volume and filling pressure.
b. Obtain serial ECGs and isoenzymes to determine
extent of myocardial injury.
c. Assess pain to differentiate myocardial pain from inci-
sional pain.
4. Monitor for hypertension or hypotension.
a. Mild systolic hypertension occurs in 48% to 55% of all
CABG patients within the first 6 hours postopera-
tively.
b. Hypotension can occur within the first 12 hours.
c. Patients with blood pressure above 70 mm Hg, with
normal preload and CO, may be treated with low-dose
dopamine.
5. Initiate measures to prevent embolization such as antiem-
bolic stockings, not putting pressure on popliteal space
(leg crossing, raising knee gatch), and starting passive and
active exercises.
a. Assess for signs of DVT and pulmonary embolism.
b. Maintain integrity of all invasive lines.
6. Monitor for bleeding.
a. Watch for steady and continuous drainage of blood.
b. Assess for arterial hypotension, low CVP, increasing
pulse rate, and low left atrial pressure and PCWP.
c. Prepare to administer blood products, I.V. solutions,
or protamine sulfate or vitamin K (AquaMEPHY-
TON).
d. Prepare for potential return to surgery for bleeding
persisting (over 300 mL/hour) for 2 hours.
e. Monitor hemoglobin levels; if the patient’s hemoglo-
bin drops below 8 g/dL, transfusions of red blood cells
or platelets may be necessary.
f. During the first 4 to 12 hours, blood recovered from
mediastinal tubes can be autotransfused to the patient.
7. Be alert for fever and signs of infection. Check blood glu-
cose levels as ordered.
a. Administer prophylactic antibiotics, as ordered, for
the first 48 hours.
b. Control higher degrees of fever through use of
hypothermia mattress.
c. Evaluate for atelectasis, pleural effusion, or pneumonia
if fever persists. (The most common cause of early
postoperative fever [within 24 hours] is atelectasis.)
d. Evaluate for urinary tract infection and wound
infection.
e. Draw blood cultures to rule out endocarditis if fever
persists.
8. Measure urine volume; less than 20 mL/hour can indicate
decreased renal function.
a. Watch BUN and serum creatinine levels as well as
urine and serum electrolyte levels.
b. Give rapid-acting diuretics and/or inotropic drugs
(dopamine [Intropin], dobutamine [Dobutrex]) to
increase CO and renal blood flow.
c. Prepare the patient for peritoneal dialysis or hemodial-
ysis if indicated. (Renal insufficiency may produce
serious cardiac dysrhythmias.)
Community and Home Care Considerations
Preparing the patient with cardiovascular disease or after car-
diac surgery for the return home and/or optimizing the
patient’s health status in the home are important nursing
functions. The key areas on which to focus include assessment,
education, and evaluating responses.
Assessment
1. Optimally, the discharge plan begins at facility admission.
The patient’s physical condition will determine to some
extent his needs at home (ie, ability to care for self).
However, the available support systems will allow the
nurse to individualize the care plan.
2. Assess the patient’s functional abilities. Patients with car-
diovascular disorders may need to conserve their energy
and rest of

HEART SURGERY
Open heart surgery is most commonly performed for CAD, valvu-
lar dysfunction, and congenital heart defects. The procedure
requires temporary cardiopulmonary bypass (blood is diverted
from the heart and the lungs and mechanically oxygenated and
circulated) to provide a dry, bloodless field during the operation.
Newer and less invasive procedures include minimally invasive
direct coronary artery bypass (MIDCAB) and port access proce-
dures. Heart transplant will not be discussed. For information on
percutaneous ventricular assist devices, see Box 12-2.
Types of Procedures
Coronary Artery Bypass Graft
1. Traditional CABG surgery involves anastomosis of a
bypass conduit or a graft (leg and arm veins) anastomosed
to the aorta, with the other end of the graft secured to a
distal portion of a coronary vessel. The graft “bypasses”
the obstructive lesion in the vessel, and adequate blood
flow is restored to the heart muscle supplied by the artery.
(The vessel of choice is usually an internal mammary
artery because it remains unobstructed for longer than
saphenous vein grafts.)
a. Multiple grafts can be placed to bypass lesions.
b. Traditional procedure is done through sternotomy.
c. The heart is stopped, and the cardiopulmonary bypass
machine is used.
2. Primarily done to alleviate anginal symptoms and
improve survival and quality of life.
3. Indications for CABG include:
a. Left main coronary artery stenosis of 70% or greater.
b. Proximal vessel disease greater than 50% to 70%
stenosis of three main coronary arteries.
c. Multivessel disease and decreased left ventricular
function.
d. UA.
e. Chronic stable angina that is lifestyle-limiting and unre-
sponsive to medical therapies or PTCA and stenting.
4. Relative contraindications for CABG include:
a. Small coronary arteries distal to the stenosis.
b. Severe aortic stenosis.
c. Severe left ventricular failure with coexisting pul-
monary, renal, carotid, and peripheral vascular disease.
Valvular Surgery
1. Prosthetic or biologic valves are placed in the heart as
definitive therapy for incompetent heart valves. Mechan-
ical valves are of man-made material and require a life-
time of therapy with anticoagulation medications.
2. Valve repair or replacement can be done in conjunction
with CABG surgery.

"If a patient is cold, if a patient is feverish, if a patient is faint, if he is sick after talking food, if he has a ded-sore, It is generally the fault not of the disease, but of the Nursing." - Mis. Florance Nightigale - - 01 Introduction She stated in her nursing notes that nursing "is an act of utilizing the environment of the patient to assist him in his recovery" Her contribution during Crimean war is well known. She was a statistician using bar and pie charts, highlighting key points. International nurses Day, May 12 is observed in respect to her contribution to Nursing. Biography of Florence Nightingale Name : Florence Nightingale (madam) Bron : Florence, Tuscany in Italy Mother : Frances Nightingale nee smith (1794-1874) Father : William Edward Nightingale (1792-1874) Date of Birth : 1820.05.12 Age : 90 Died : 13 August 1910 Known for : Pioneering modern nursing Lernt : Latin, German, French, Italian, Greek, Mathematics, Science, Politics, Music, Drawing Awards : Royal Red Cross 1883 Order of Merit (1907) Nationality : British - 01 The English nurse Florence Nightingale was the founder of Modern nursing and made outstanding contributions to the knowledge and improvement of public heath. Florence Nightingale was born in Florence, Italy. On May 12.1820. She was named after the city of her birth. Her father is Willicim Edward Nightingale. And was a wealthy landowner who had inherited and estates in Derbyshire England. Like many members of the wealthy class, he had Florence's mother fanny, dedicated themselves to the pursuit of active social lives. Florence and her sister, Parthenope were tutored by their father in languages, mathematics and history. Through Florence was tempted by the idea of a brilliant social life and marriage, she also wanted to achieve independence. The Nightingales lived at Lea Hall from 1821 to 1825,until their new home. Lea hurts was completed However, Fanny deemed Lea hurts inadequate almost immediately, with "only 15 bedrooms" and located too far form London. It became their summer home. William purchased Embley Park, a Large estate in hampshire, which became their permanent residence. It was at Embley park in February 1837 that Florence received a calling form God: she wrote, "God has spoke to me and called me to his service" Through she did not know what that service would be, she knew that society life her parents and sister enjoyed so much was not going to be enough for her. Nightingale was attractive, slender and graceful. While her demeanor was often sever, She could be very charming and her smile was radiant. Florence Nightingale treates captain an injured dog. Florence Nightingale In The Crimean War England and France were helping Turkey in a war against Russia. Ÿ Russia and France had religious sisters to care for their wounded. Ÿ But England had only trained men. Ÿ Florence Nightingale received a letter of apple from the minister of war. Ÿ With 38 nurses form catholic and protestant olders she set for crimea.

Nursing Diagnosis List
The list or database of NANDA nursing diagnoses examples with their definitions that you can read to learn more about them or use them in developing your nursing care plans.
• Activity Intolerance: Insufficient physiologic or psychological energy to endure or complete required or desired daily activities.
• Acute Confusion: Abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, or the sleep/wake cycle.
• Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months.
• Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.
• Bowel Incontinence: Change in normal bowel habits characterized by involuntary passage of stool.
• Caregiver Role Strain: Difficulty in performing family caregiver role.
• Chronic Confusion: An irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli, decreased capacity for intellectual thought processes, and manifested by disturbances of memory, orientation, and behavior.
• Chronic Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage…a duration of greater than 6 months.
• Constipation: Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool.
• Decreased Cardiac Output: Inadequate blood pumped by the heart to meet the metabolic demands of the body.
• Deficient Fluid Volume: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.
• Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.
• Diarrhea: This nursing diagnosis is defined as passage of loose, unformed stools.
• Disturbed Body Image: Confusion in mental picture of one’s physical self.
• Disturbed Thought Processes: The state in which an individual experiences a disruption in such mental activities as conscious thought, reality orientation, problem solving, judgment, and comprehension related to coping, personality, and/or mental disorder.
• Excess Fluid Volume: Increased isotonic fluid retention.
• Fatigue: An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.
• Fear: Response to perceived threat that is consciously recognized as danger.
• Grieving: A normal complex process that includes emotional, physical, spiritual, social, and intellectual responses and behaviors by which individuals, families, and communities incorporate an actual, anticipated, or perceived loss into their daily lives.
• Hopelessness: Subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on own behalf.
• Hyperthermia: Body temperature elevated above normal range.
• Hypothermia: Body temperature below normal range.
• Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients insufficient to meet metabolic needs.
• Imbalanced Nutrition: More Than Body Requirements: Intake of nutrients that exceeds metabolic needs.
• Impaired Dentition: Disruption in tooth development or eruption patterns or structural integrity of the teeth
• Impaired Gas Exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.
• Impaired Oral Mucous Membrane: Disruption of the lips and/or soft tissue of the oral cavity.
• Impaired Physical Mobility: Limitation in independent, purposeful physical movement of the body or of one or more extremities.
• Impaired Swallowing: Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function.
• Impaired Tissue (Skin) Integrity: Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues.
• Impaired Urinary Elimination: Dysfunction in urinary elimination.
• Insomnia: A disruption in amount and quality of sleep that impairs functioning.
• Impaired Verbal Communication: Decreased, reduced, delayed, or absent ability to receive, process, transmit, and use a system of symbols.
• Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
• Ineffective Breathing Pattern: Inspiration and/or expiration that does not provide adequate ventilation.
• Ineffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.
• Ineffective Therapeutic Regimen Management: Pattern of regulating and integrating into daily living a program for treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health goals.
• Ineffective Tissue Perfusion: Decrease in oxygen, resulting in failure to nourish tissues at capillary level.
• Insomnia: A disruption in amount and quality of sleep that impairs functioning.
• Latex Allergy Response: A hypertensive reaction to natural latex rubber products.
• Powerlessness: Perception that one’s own action will not significantly affect an outcome; a perceived lack of control over a current situation or immediate happening.
• Rape Trauma Syndrome: Sustained maladaptive response, violent sexual penetration against the victim’s will and consent.
• Risk for Aspiration: At risk for entry of gastrointestinal secretions, oropharyngeal secretion, solids, or fluids into tracheobronchial passages.
• Risk for Bleeding: At risk for a decrease in blood volume that may compromise health.
• Risk for Electrolyte Imbalance: At risk for change in serum electrolyte levels that may compromise health.
• Risk for Falls: Increased susceptibility to falling that may cause physical harm.
• Risk for Impaired Skin Integrity: At risk for skin being adversely altered.
• Risk for Infection: At increased risk for being invaded by pathogen organisms.
• Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.
• Risk for Suicide: At risk for self-inflicted, life-threatening injury.
• Risk for Unstable Blood Glucose Level: Risk for variation of blood glucose/sugar levels from the normal range.
• Self-Care Deficit: Impaired ability to perform or complete activities of daily living for oneself, such as feeding, dressing, bathing, toileting.
• Situational Low Self Esteem: Development of a negative perception of self-worth in response to current situation.
• Urinary Incontinence, Functional: Inability of usually continent person to reach toilet in time to avoid unintentional loss of urine.
• Urinary Incontinence, Reflex: Involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached.
• Urinary Incontinence, Stress: Sudden leakage of urine with activities that increase intra abdominal pressure.
• Urinary Incontinence, Urge: Involuntary passage of urine occurring soon after a strong sense of urgency to void.
• Urinary Retention: Incomplete emptying of the bladder.