NOTE: Delayed distention of the neck veins should not be confused with the transitory
distention seen postoperatively as the patient throws off unconsciousness produced by
anesthesia. This distention is usually the result of straining.
b. Nursing Implications.
Report signs and symptoms to the RN immediately.
Monitor pulse and blood pressure.
Administer oxygen as ordered for dyspnea.
(4) Assist with diagnostic procedures such as chest X-ray, ECG, or cardiac
(5) Assist with procedures to relieve pressure and remove fluid such as
thoracotomy or needle aspiration of the pericardial cavity.
1-39. RENAL FAILURE
a. Impairment of renal function may be caused by decreased cardiac output
associated with open-heart surgery or by red blood count (RBC) hemolysis caused by
the trauma of cardiopulmonary bypass.
b. Nursing implications when renal failure is suspected include the following:
Strict and accurate recording of intake and output.
Measurement of urine output on an hourly basis.
(3) If a urine output of less than 20 cc/hr is obtained, immediate notification
should be made to the RN.
(4) Routine specific gravity of urine should be performed and recorded.
(Specific gravity provides information relative to kidney function.)
1-40. MYOCARDIAL INFARCTION
a. A MI may occur during the postoperative period. Symptoms, however, may
be masked by the postoperative pain being experienced by the patient.