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Nursing Care Plan

Nursing Diagnosis
Decreased cardiac output related to decreased myocardial contractility

Long Term Goal:
Patient will display hemodynamic stability (BP, cardiac output, urinary output and peripheral pulses WNL)

Short Term Goals / Outcomes:
Patients lungs sounds will be clear to auscultation
Patient will have no signs of dyspnea
Patient will demonstrate an increase in activity intolerance

Intervention

Rationale

Evaluation

Assess patient respirations by observing respiratory rate and depth and use of accessory muscles

Increased respiratory rate and use of accessory muscles may be seen in patients with hypoxia

Patient has regular, even, non-labored respirations.

Observe patient for restlessness, agitation, confusion and (late stages) lethargy

Changes in behavior and mental status can be early signs of impaired gas exchange which will result from decreased cardiac output

Patient will be alert, oriented x 3 and calm

Auscultate lungs for presence of normal or adventitious lung sounds

Crackles may indicate heart failure which can contribute to decreased cardiac output.  Respiratory distress/failure often occurs as shock progresses.

Patient’s lungs sounds are clear to auscultation in all lobes

Assess patient for positive hepatojugular reflex

A positive hepatojugular reflex is indicative of right-sided heart failure

Patient has normal hepatojugular reflex.

Assess for mental status changes.

Increasing lethargy, confusion, restlessness and / or irritability can be early signs of cerebral hypoxia from decreased cardiac output

Patient is awake, alert and oriented X3.

Weigh patient daily at same time with same clothing on same scale.

Weight gain can be one of the earliest indicators of heart failure as a result of impaired ventricular pumping ability.  An acute gain in weight of 1kg. can signal a l liter gain in fluid

Patient maintains baseline weight or less daily

Observe patient for sleep apnea

Sleep apnea is a common disorder in patients with chronic heart failure

Patient will have no episodes of sleep apnea

Assess patient for chest pain or discomfort noting location, severity, duration, quality and radiation

Chest pain is generally indicative of inadequate blood supply to the heart which can result in decreased cardiac output

Patient is free of chest pain.

Elevate legs when in sitting position and edematous extremities when at rest

Improves venous return and increases cardiac output

Patient will have decreased edema in legs

Monitor hourly urine output

Decreased cardiac output results in decreased perfusion to the kidneys and decreased urine output.  Urinary output < 30 ml/hr. indicates inadequate renal perfusion.

Patient will have a minimum of 30ml/hr. urinary output

Assess patient heart sounds

Heart sounds may sound distant and have an S3 or S4 sound present with the presence of heart failure

Patient has normal heart sounds of S1 and S2

Monitor patient for changes in heart rate and/or rhythm

Heart irritability is common with conduction defects and/or ischemia from a poorly perfused heart (Tachycardia at rest, atrial fibrillation, bradycardia, or multiple dysrhythmias)

Patient will have normal sinus rhythm

Assess peripheral pulses

Weak, thready peripheral pulses may reflect hypotension, vasoconstriction, shunting and venous congestion

Patient will have strong, palpable peripheral pulses in all extremities

Observe patient for changes in skin color, moisture, temperature and capillary refill time

Pallor or cyanosis, cool moist skin and slow capillary refill time may be present from peripheral vasoconstriction and decreased oxygen saturation

Patient will have normal skin color, be dry to touch and have capillary refill time of 3 seconds or less or 5 seconds or less (if patient is elderly)

Administer supplemental Oxygen as indicated by cannula, mask, or ET/trach tube.

Supplemental oxygen helps to improve cardiac function by increasing available oxygen and reducing oxygen consumption

Patient’s oxygen saturation will remain at 93% or above at all times.

Promote rest

Rest and a quiet environment reduces a catecholamine-induced stress response and decreases cardiac workload thus increasing cardiac output

Patient will get adequate rest in a stress-free environment.

Educate patient and caregivers about the importance of taking prescribed medications at prescribed times

Patient is often on multiple medications which can be difficult to manage, thus increasing the likelihood that medications can be missed or incorrectly used

Patient and/or caregiver will verbalize an understanding of patient medications and dosing schedule.






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