Question

The client is admitted to the intensive care area following a coronary artery bypass graft. The nurse caring for the client manages the fluid volume status by checking the central venous pressure and finds a reading of \(4 \mathrm{~mm} \mathrm{Hg}\). Which action should the nurse take at this time? A. Increase the rate of IV fluid using the protocol provided B. Continue her care with no further action C. Decrease the IV fluid using the protocol provided D. Administer furosemide (Lasix) as ordered

Short answer

Answer: B. Continue her care with no further action.

Step-by-step solution

Understand the normal range of central venous pressure

The normal range of central venous pressure (CVP) is around 2 to 8 mm Hg. A CVP of 4 mm Hg is within the normal range which indicates that fluid volume status is adequate.

Evaluate the options provided

A. Increase the rate of IV fluid using the protocol provided - This option is not recommended as the CVP is within the normal range, meaning that the fluid volume status is adequate. B. Continue her care with no further action - This option might be appropriate since the CVP is within the normal range. The nurse may continue monitoring the patient's condition without making changes in fluid management. C. Decrease the IV fluid using the protocol provided - This option is also not recommended because the CVP is within the normal range, indicating that fluid volume status is adequate. D. Administer furosemide (Lasix) as ordered - This is a diuretic and would be used for high CVP. Considering that the CVP of 4mm Hg is not elevated, this option is not appropriate.

Choose the correct answer

Based on the analysis of the options and understanding of the normal range of central venous pressure, the correct answer is: B. Continue her care with no further action

Key concepts

Coronary Artery Bypass Graft Care

Coronary artery bypass graft (CABG) is a type of surgery used to improve blood flow to the heart. This procedure is often done to relieve symptoms of coronary artery disease, such as chest pain, by bypassing clogged arteries. After surgery, the primary focus shifts to postoperative care, essential to ensure a smooth recovery and avoid complications.
Key aspects of post-CABG care include: - **Pain Management:** Patients may experience pain at the incision site and in their chest area, requiring regular assessment and management usually with prescribed pain medications. - **Monitoring Vital Signs:** Continuous monitoring of blood pressure, heart rate, and oxygen levels helps ensure stability. - **Preventing Infections:** Proper wound care and hygiene practices are vital to prevent infections, particularly at the incision sites. - **Encouraging Mobility:** Early and gradual mobilization is encouraged to improve cardiovascular function and reduce the risk of blood clots. The goal of care is to support heart function, manage symptoms, and keep any potential complications in check, aiding a return to daily activities.

Central Venous Pressure

Central venous pressure (CVP) is an important measurement used in intensive care settings. It assesses the fluid volume status of patients, providing insight into cardiac function and venous blood return to the heart. Normal CVP readings range from 2 to 8 mm Hg. A CVP of 4 mm Hg falls within this range, suggesting adequate fluid volume, meaning neither overhydration nor dehydration. This measurement is especially critical in patients following surgeries like coronary artery bypass grafting where fluid management is crucial.
Key factors affecting CVP include: - **Blood Volume:** Alterations in blood volume, through loss or gain of fluid, can change CVP readings. - **Heart Function:** Heart disorders that affect how blood is pumped can also impact CVP. - **Venous Return:** Changes in venous pressure can influence the amount of blood returning to the right atrium, affecting CVP. Monitoring CVP helps in making informed decisions about fluid management to stabilize patients' conditions.

Fluid Volume Management

Fluid volume management involves maintaining a proper balance of fluids in the body, which is critical in post-operative care. This aspect of care ensures that the body functions optimally, avoiding both fluid overload and dehydration, both of which can cause complications. After procedures like CABG, monitoring of fluid intake and output is crucial. Nurses often rely on CVP readings to guide fluid therapy since they provide immediate feedback on the patient’s volume status.
Techniques in fluid management include: - **Intravenous Fluids:** Adjusting IV fluid rates based on ongoing assessments helps maintain balance. - **Diuretics Use:** In cases of fluid overload, diuretics like furosemide may be used to remove excess fluid. - **Oral Hydration:** Encouraging adequate oral fluid intake, considering dietary restrictions and patient needs. The aim is to prevent complications such as swelling, high blood pressure, or strain on the heart, thus facilitating recovery.

Nursing Interventions

Nursing interventions are actions undertaken by nurses to enhance patient health and are especially significant in the context of post-surgical care. Nurses play an essential role in monitoring, assessment, and implementation of care plans tailored to each patient's unique needs. Important nursing interventions post-CABG include: - **Monitoring Fluid Status:** Regularly assessing CVP and urine output ensures proper fluid balance. - **Encouraging Activity:** Assisting patients with gentle exercises and mobilization aids in recovery and prevents complications like thrombosis. - **Educating Patients:** Teaching patients about their medications, dietary guidelines, and activity restrictions is vital for ongoing recovery. - **Emotional Support:** Providing emotional support to patients and their families helps cope with the stress of surgery and recovery. These interventions are designed to promote healing, prevent complications, and support the patient’s overall well-being as they recover from cardiac surgery.