Nursing Care Plans for Decreased Cardiac output

Posted by d.nurisna at Friday, February 27, 2009 . Friday, February 27, 2009 Labels: NURSING CARE PLANS, NURSING DIAGNOSIS Nursing Diagnosis: Decreased Cardiac output Nursing Care Plans for Decreased Cardiac output NANDA Definition: Inadequate blood pumped by the heart to meet metabolic demands of the body Defining Characteristics: Altered heart rate/rhythm: arrhythmias (tachycardia, bradycardia); palpitations; EKG changes; altered preload: jugular vein distention; fatigue; edema; murmurs; increased/decreased central venous pressure (CVP); increased/decreased pulmonary artery wedge pressure (PAWP); weight gain; altered afterload: cold/clammy skin; shortness of breath/dyspnea; oliguria; prolonged capillary refill; decreased peripheral pulses; variations in blood pressure readings; increased/decreased systemic vascular resistance (SVR); increased/decreased pulmonary vascular resistance (PVR); skin color changes; altered contractility: crackles; cough; orthopnea/paroxysmal nocturnal dyspnea; cardiac output less than 4 L/min; cardiac index less than 2.5 L/min; decreased ejection fraction, stroke volume index (SVI), left ventricular stroke work index (LVSWI); S3 or S4 sounds; behavioral/emotional: anxiety ; restlessness Related Factors: Myocardial infarction or ischemia, valvular disease, cardiomyopathy, serious dysrhythmia, ventricular damage, altered preload or afterload, pericarditis, sepsis, congenital heart defects , vagal stimulation, stress, anaphylaxis, cardiac tamponade NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Cardiac Pump Effectiveness Circulatory Status Tissue Perfusion: Abdominal Organs Tissue Perfusion: Peripheral Vital Signs Status Client Outcomes
y

y y

Demonstrates adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters for client; strong peripheral pulses; and an ability to tolerate activity without symptoms of dyspnea, syncope, or chest pain Remains free of side effects from the medications used to achieve adequate cardiac output Explains actions and precautions to take for cardiac disease

NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels

 Cardiac Care: Acute Circulatory Care Nursing Interventions and Rationales

y

y y

y y

Monitor for symptoms of heart failure and decreased cardiac output, including diminished quality of peripheral pulses, cool skin and extremities, increased respiratory rate, presence of paroxysmal nocturnal dyspnea or orthopnea, increased heart rate, neck vein distention, decreased level of consciousness, and presence of edema. As these symptoms of heart failure progress, cardiac output declines. Listen to heart sounds; note rate, rhythm, presence of S3, S4, and lung sounds. The new onset of a gallop rhythm, tachycardia, and fine crackles in lung bases can indicate onset of heart failure. If client develops pulmonary edema, there will be coarse crackles on inspiration and severe dyspnea. Observe for confusion , restlessness, agitation, dizziness. Central nervous system disturbances may be noted with decreased cardiac output. Observe for chest pain or discomfort; note location, radiation, severity, quality, duration, associated manifestations such as nausea, and precipitating and relieving factors. Chest pain/discomfort is generally indicative of an inadequate blood supply to the heart, which can compromise cardiac output. Clients with heart failure can continue to have chest pain with angina or can reinfarct. If chest pain is present, have client lie down, monitor cardiac rhythm, give oxygen, run a strip, medicate for pain, and notify the physician. These actions can increase oxygen delivery to the coronary arteries and improve client prognosis. Place on cardiac monitor; monitor for dysrhythmias, especially atrial fibrillation. Atrial fibrillation is common in heart failure. Monitor hemodynamic parameters for an increase in pulmonary wedge pressure, an increase in systemic vascular resistance, or a decrease in cardiac output and index. Hemodynamic parameters give a good indication of cardiac function. Titrate inotropic and vasoactive medications within defined parameters to maintain contractility, preload, and afterload per physician's order. By following parameters, the nurse ensures maintenance of a delicate balance of medications that stimulate the heart to increase contractility, maintaining adequate perfusion of the body. Monitor intake and output. If client is acutely ill, measure hourly urine output and note decreases in output. Decreased cardiac output results in decreased perfusion of the kidneys, with a resulting decrease in urine output. Note results of EKG and chest Xray. EKG can reveal previous MI,or evidence of left ventricular hypertrophy, indicating aortic stenosis or chronic systemic hypertension . Xray may provide information on pulmonary edema, pleural effusions, or enlarged cardiac silhouette found in dilated cardiomyopathy or large pericardial effusion. Results of diagnostic imaging studies such as echocardiogram, radionuclide imaging or dobutamine stress echocardiography. The echocardiogram is the most important imaging tool for evaluation patients with symptoms of heart failure because overall systolic function and chamber size can be evaluated quickly. In addition, global versus regional left ventricular function, valvular abnormalities, and diastolic function can be defined,

y y y

assisting in differential diagnosis. An ejection fraction in a healthy heart is approximately 50%. Most patients experiencing heart failure have an ejection fraction of less than 40%. Watch laboratory data closely, especially arterial blood gases and electrolytes, including potassium. Client may be receiving cardiac glycosides and the potential for toxicity is greater with hypokalemia; hypokalemia is common in heart clients because of diuretic use. Monitor lab work such as complete blood count, sodium level, and serum creatinine. Routine blood work can provide insight into the etiology of heart failure and extent of decompensation. A low serum sodium level often is observed with advanced heart failure and can bea poor prognostic sign. Serum creatinine levels will elevate in clients with severe heart failure because of decreased perfusion to the kidneys.Creatinine may also elevate because of ACE inhibitors. Administer oxygen as needed per physician's order. Place client in semi-Fowler's position or position of comfort. Elevating the head of the bed may decrease the work of breathing, and also decrease venous return and preload. Check blood pressure, pulse, and condition before administering cardiac medications such as angiotensin converting enzyme (ACE) inhibitors, digoxin, and beta-blockers such as carvedilol. Notify physician if heart rate or blood pressure is low before holding medications. It is important that the nurse evaluate how well the client is tolerating current medications before administering cardiac medications; do not hold medications without physician input. The physician may decide to have medications administered even though the blood pressure or pulse rate has lowered. During acute events, ensure client remains on bed rest or maintains activity level that does not compromise cardiac output. In severe heart failure, restriction of activity often facilitates temporary recompensation. Gradually increase activity when client's condition is stabilized by encouraging slower paced activities or shorter periods of activity with frequent rest periods following exercise prescription; observe for symptoms of intolerance. Take blood pressure and pulse before and after activity and note changes. Activity of the cardiac client should be closely monitored. See Activity intolerance . Serve small sodium-restricted, low-cholesterol meals. Give only small amounts of caffeine-containing beverages, if no resulting dysrhythmia. Sodium-restricted diets help decrease fluid volume excess. Low-cholesterol diets help decrease atherosclerosis, which causes coronary artery disease. Clients with cardiac disease tolerate smaller meals better because they require less cardiac output to digest. One cup of caffeinated coffee has generally not been found to have any significant effect (Schneider, 1987; Powell, 1993). Monitor bowel function. Provide stool softeners as ordered. Caution client not to strain when defecating. Decreased activity can cause constipation. Straining when defecating that results in the Valsalva maneuver can lead to dysrhythmia, decreased cardiac function, and sometimes death. Have clients use a commode or urinal for toileting and avoid use of a bedpan. Getting out of bed to use a commode or urinal does not stress the heart any more than staying in bed to toilet. In addition, getting the client out of bed minimizes complications of immobility and is often preferred by the client.

y y y

Provide a restful environment by minimizing controllable stressors and unnecessary disturbances. Schedule rest periods after meals and activities. Rest periods decrease oxygen consumption. Weigh client at same time daily. An accurate daily weight is a good indicator of fluid balance. Increased weight and severity of symptoms can signal decreased cardiac function with retention of fluids. Assess for presence of anxiety; see interventions for Anxiety to facilitate reduction of anxiety in clients and family. Consider using music to decrease anxiety and improve cardiac function. Music has been shown to reduce heart rate, blood pressure, anxiety, and cardiac complications. Closely monitor fluid intake including IV lines. Maintain fluid restriction if ordered. In clients with decreased cardiac output, poorly functioning ventricles may not tolerate increased fluid volumes. Refer to heart failure program or cardiac rehabilitation program for education, evaluation, and guided support to increase activity and rebuild life. Exercise can help many patients with heart failure. Whereas rest was commonly recommended a few years ago, it has become clear that inactivity can worsen the skeletal muscle myopathy in these patients.A carefully monitored exercise program can improve both functional capacity, and left ventricular function. Exercise based cardiac rehabilitation programs apppear to be effective in reducing cardiac deaths, but the evidence base is weakened by poor quality trials.