About
Removal of patient heart and transplant of matched donor heart.
Assess
Heart sounds, vitals signs, signs of organ rejection, signs of infection, vitals, pulse-oximetry, pain levels, lung sounds, incision ( redness, drainage, bleeding, bruising)
Complications
Infection, rejection, atherosclerosis, hypertension, osteoporosis, immunosuppression, malignancy, post-operative complications
Diagnosis
- Risk for infection related to immunosuppression and surgical intervention.
- Risk for injury related to organ rejection.
- Acute pain related to actual tissue damage
- Deficient knowledge related to post surgical treatment regimen
- Impaired skin integrity related to surgical intervention.
- Ineffective coping related to receiving a donor organ.
Goals
- The client will remain free from infection.
- The client will be free form signs of organ rejection.
- The client will understand pre-, intra-, and post-operative instructions.
- The client will remain free from post-operative complications.
- The client will have incision closed, well approximated without evidence of bruising or bleeding.
- The client will perform coughing and deep breathing exercises at least ten times an hour while awake.
Interventions
- Monitor for signs and symptoms of infection.
- Monitor for signs and symptoms of rejection.
- Monitor vital signs every 15 minutes X 2, 30 minutes X2, one hour X2, than every 4 hours ( may have different guidelines for each clinical agency).
- Monitor for signs and symptoms of infection.
- Assess lung sounds, pulse oximetry, bowel sounds, circulation frequently.
- Implement incentive spirometry pre-operatively.
- Encourage to do IS post-operatively at least ten times an hour.
- Teach abdominal splinting.
- Apply elastic compression stockings and/or sequential compression device as ordered.
- Maintain NPO prior to surgery and start with clear liquids after surgery.
- Encourage early ambulation to avoid complications.
- Teach client signs and symptoms requiring immediate follow-up by a health care provider ( chest pain, fever, difficulty breathing)
- Monitor for signs/ symptoms of complications.
- Teach client to have 20-30 minute warm-up and cool-down with exercise.
- Teach client to maintain compliance with anti-rejection drugs.
- Teach client to avoid individuals with infection or virus.
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