May be related to
Sternotomy (mediastinal incision) or donor site (leg or arm incision)
Myocardial ischemia (acute MI, angina)
Tissue inflammation, edema formation
Intraoperative nerve trauma
Possibly evidenced by
Reports of incisional discomfort or pain; paresthesia; pain in hand, arm, shoulder
Anxiety, restlessness, irritability
Increased heart rate
Desired Outcomes/Evaluation Criteria—Client Will
Verbalize relief or absence of pain.
Demonstrate relaxed body posture and ability to rest and sleep appropriately.
Differentiate surgical discomfort from angina or preoperative heart pain.
Nursing care plan intervention with rationale:
1. Note type and location of incision(s).
Rationale: Newer procedures, such as MIDCAB, require smaller chest and leg incisions, with less significant pain. Many CABG clients do not experience severe discomfort in chest incision and may complain more often of donor site incision discomfort. Severe pain in either area should be investigated further for possible complications.
2. Encourage client to report type, location, and intensity of pain, rating it on a scale. Note associated symptoms. Ascertain how this compares with preoperative chest pain.
Rationale: Pain is perceived, manifested, and tolerated individually. It is important for client to differentiate incisional pain from other types of chest pain, such as angina or discomfort from chest tubes.
3. Observe for anxiety, irritability, crying, restlessness, and sleep disturbances.
Rationale: These nonverbal cues may indicate the presence or degree of pain being experienced.
4. Monitor vital signs.
Rationale: Heart rate usually increases with acute pain, although a bradycardiac response can occur in a severely diseased heart. BP may be elevated slightly with incisional discomfort, but may be decreased or unstable if chest pain is severe or myocardial damage is occurring.
5. Identify and promote position of comfort, using adjuncts as necessary.
Rationale: Pillows or blanket rolls are useful in supporting extremities, maintaining body alignment, and splinting incisions to reduce muscle tension and promote comfort.
6. Provide comfort measures, such as back rubs and position changes, assist with self-care activities, and encourage diversional activities, as indicated.
Rationale: May promote relaxation, redirect attention, and reduce analgesic dosage needs or frequency.
7. Schedule care activities to balance with adequate periods of sleep and rest.
Rationale: Rest and sleep are vital for cardiac healing (balance between oxygen demand and consumption) and can enhance coping with stress and discomfort.
8. Identify and encourage use of behaviors such as guided imagery, distractions, visualizations, and deep breathing.
Rationale: Relaxation techniques aid in management of stress, promote sense of well-being, may reduce analgesic needs, and promote healing.
9. Tell client that it is acceptable, even preferable, to request analgesics as soon as discomfort becomes noticeable.
Rationale: Presence of pain causes muscle tension, which can impair circulation, slow healing process, and intensify pain.
10. Medicate before procedures and activities, as indicated.
Rationale: Client participation in respiratory treatments, ambulation, and procedures, such as removal of chest tubes, pacemaker wires, and sutures, are facilitated by maximum analgesic blood level.
11. Investigate reports of pain in unusual areas, for instance, calf of leg or abdomen, or vague complaints of discomfort, especially when accompanied by changes in mentation, vital signs, and respiratory rate.
Rationale: May be an early manifestation of developing complication, such as thrombophlebitis, infection, and gastrointestinal dysfunction.