Nursing Diagnosis: Decreased cardiac output r/t impaired contractility of the heart, secondary to CHF, AEB weak peripheral

pulses, ARF, fatigue, and hx of AFIB

Long Term Goal: Pt will have adequate cardiac output

OUTCOME
CRITERIA
1.

2.

INTERVENTIONS

Pts BP will remain between

90/50-140/90mmHg; pulse
60-100bpm, regular rhythm;
respirations 12-20 per minute,
easy and unlabored; O2 sat
95-100%; and temp 96.8100.4F as assessed q4h

Independent/Assess:

Pt will remain alert and

oriented to person, place, and
time as assessed and at all
times

Independent/Assess:

Assess vital signs and O2

sat q4h and PRN

RATIONALE

EVALUATION

Most patients have compensatory

tachycardia and significantly decrease BP in
response to reduced cardiac output. Rapid
shallow respirations are characteristic of
reduced cardiac output. O2 sat would
decrease if blood was not adequately
perfusing the extremities. A decrease in
temp could also indicate inadequate
perfusion. Since this pt has CHF, Afib, and
fatigue, monitoring vitals would/could
indicate a change in health status (NCP
Gulanick/Myers p38).

Partially met. All

vitals were WNL
except respirations.
Respirations were
increased but pt
showed no other s/s
of distress.

A change in LOC is indicative of decreased

cerebral tissue perfusion and hypoxia.
Assess for any changes in Restlessness, irritability, and difficulty
concentrating may precede a change in
LOC q4h and PRN
LOC. If these s/s were to occur, they would
indicate reduced cerebral tissue perfusion
and require prompt intervention. A decrease
in cerebral tissue perfusion would be due to
decreased CO because the heart cant
contract well enough to get blood to the
brain (NCP Gulanick/Myers p38).

Outcome criteria
met.

3.

4.

Pt will maintain adequate

fluid balance and not gain
>2lbs per day when assessed
qday and PRN

Independent/Assess:

Pt will have S1 and S2 heart

sounds, and be free of S3 or
S4 heart sounds when
assessed q4h

Independent/Assess:

Assess fluid balance and

weight gain qday and
PRN

Assess heart sounds by

auscultating apical pulse
for 1 full min q4h

This pt has CHF, and acute renal failure.

One of the clinical manifestations of CHF is
excess fluid volume which increases
preload and afterload therefore decreasing
cardiac output. On admission the pt had s/s
oliguria, which is a sign of decreased renal
perfusion. Since the heart pumps blood to
the kidneys, which filter and excrete excess
fluid, ARF can compromise u/o and lead to
FVE (which decreases CO) (NCP
Gulanick/Myers p38).

Outcome criteria
met.

S1 and S2 heart sounds are normal/expected Outcome criteria

sounds (Lub/Dub). S3 or S4 sounds are
met.
abnormal. S3 sounds indicate excess fluid
volume and S4 sounds indicate stiff
ventricular wall. Since this pt has CHF, it is
essential to listen for abnormal heart sounds
to monitor for a change or worsening
condition. Impaired contractility of the heart
can lead to S3/S4 sounds which indicate
problems that can lead to decreased
peripheral pulses and renal perfusion (NCP
Gulanick/Myers p38).

5.

6.

Pt will be free of c/o fatigue

and will tolerate activities
when assessed q4h and PRN

Independent/Assess:

Pt will be free of c/o chest

pain when assessed q4h and
PRN

Independent/Assess:

Assess for reports of

fatigue and reduced
activity intolerance q4h
and PRN

Assess for chest pain q4h

and PRN

Low CO states can cause fatigue and

Unmet. When pt
exertional dyspnea d/t decreased
ambulated c/o
oxygenation of tissues. This pt has COPD as weakness.
well as CHF, so it is important to monitor
pts response to increase activity as
indicated. Activity promotes circulation and
therefore will increase tissue perfusion. The
increased tissue perfusion will strengthen
peripheral pulses and adequately perfuse the
tissues (NCP Gulanick/Myers p39).

The heart muscle can also have decreased

Outcome criteria
perfusion d/t decreased CO. If a lack of O2
met.
to the heart occurs, it presents as chest pain.
A myocardial infarction can be lifethreatening. Asking the pt if they have chest
pain can indicate if an MI is occurring.
Since this pt has CAD, ischemia may occur.
Pt also has DM, and may not feel pain d/t
neuropathy so other labs should be
monitored to also assess for an MI.
Decreased CO will lead to decreased
amounts of oxygen in the blood, which
decreases the O2 supply to the heart and this
presents as chest pain (NCP
Gulanick/Myers p39).

7.

8.

Pts peripheral pulses will

remain present at least 1+
strength/amplitude and cap
refill <3 seconds when
assessed q4h and PRN

Independent/Assess:

Pts HR will remain between

60-100bpm at a regular
rhythm at all times while
receiving Sotalol

Dependent:

Assess peripheral pulses

and capillary refill q4h
and PRN

Administer Sotalol PO
q24hrs (40mg)
(Betapace) per MD order

This pt is a 91 year old with a diagnosis of

CHF. This particular pt had peripheral
pulses at 1+amplitude. Stating an outcome
of 2+amplitude may not be possible for this
pt. The peripheral pulses may indicate
reduced circulatory efficacy, but they were
present and skin was warm. Cap refill also
monitors blood flow to extremities and
should be brisk (<3 seconds) to indicate
adequate circulation. Impaired contractility
means the heart doesnt have enough
strength to pump blood to all the
extremities, so peripheral pulses and cap
refill should be monitored (NCP
Gulanick/Myers p38)

Outcome criteria
met.

Sotalol is a class III antiarrhythmic. Since

Outcome criteria
the pt has a diagnosis of Afib, it is important met.
to maintain NSR. Atrial fibrillation
compromises CO because the atria only
quiver instead of adequately pumping and
giving the atrial kick. A lack of atrial kick
results in 30% decrease of CO. Maintaining
NSR results in increased effectiveness of
the heart and adequate CO (NCP
Gulanick/Myers p39/Davis Drug Guide
online)

9.

10.

Pts BP will remain between

90/50-140/90mmHg at all
times while receiving
Olmesartan

Dependent:

Pts BP will remain between

90/50-140/90mmHg within
approximately 3 days after
initiating Lasix therapy

Dependent:

Administer Olmesartan
tab PO qday (20mg)
(Benicar) per MD order

Administer Furosemide
tab PO qday (20mg)
(Lasix) per MD order

Pt has hx of HTN which increases afterload.

Afterload is the resistance the left ventricle
must overcome to circulate blood. Increased
afterload means increased cardiac workload
and increased stress on the left ventricle. If
the left ventricle is weak it can not pump
effectively which will decrease CO.
Keeping BP within an acceptable range
decreases afterload and improves CO.
Olmesartan is an angiotensin II receptor
antagonist which acts to decerease BP.
Impaired contractility means the heart
doesnt beat strong enough to circulate
blood (NCP Gulanick/Myers p39/Davis
Drug Guide online).

Outcome criteria
met.

Lasix is a loop diuretic. It initiates dieresis

Outcome criteria
(excretion of fluids) which decreases
met.
preload and therefore decreases BP. An
increased BP increases afterload and cardiac
workload especially for the left ventricle. If
the left ventricle does not pump effectively,
it will result in decreased CO. Keeping BP
and fluid status within an acceptable range
decreases afterload and improves CO.
Impaired contractility means the heart
doesnt beat strong enough to circulate
blood thoroughly. Increased afterload
(FVE) places even more pressure on the left
ventricle to pump blood (NCP
Gulanick/Myers p39/Davis Drug Guide
online).

11.

12.

Pts O2 sat will remain at or

above 92% when assessed
q4h

Dependent/Collaborate:

Pts heart will not show

significant changes on an
echocardiogram as ordered by
MD

Dependent/Collaborate:

Obtain MD order for O2

3LPM NC

Obtain MD order for an

echocardiogram to
monitor for changes in
heart structure

Since this pt has pneumonia and COPD,

they are at risk for respiratory distress and
decreased oxygen consumption. This pt also
has CHF which means the heart is not
working/pumping as effectively as it should
be. A failing heart may not be able to
respond to increased O2 demands, so
supplemental O2 will help keep O2
saturation at least 92% (NCP
Gulanick/Myers p39).

Outcome criteria
met.

An echocardiogram allows assessment of

size/shape of the heart, the hearts pumping
strength, valve regurgitation or stenosis, and
how the heart moves. This pt has a dx of
CHF and has had aortic valve replacement.
One echo was performed and results
showed left ventricular hypertrophy. This
thickening of the left ventricle can
eventually lead to weakness, and also
decreased CO from impaired contractility.
By monitoring for worsening changes,
further intervention can be performed
(heart.org/mayoclinic.com)

Unmet. Pt only had

one echo on file.

13.

14.

Pts BUN will remain

between 7-21mg/dL and
creatinine 0.6-1.3mg/dL when
resulted from labs ordered by
MD

Dependent/Monitor:

Pts BNP will be <100 when

resulted from labs as ordered
by MD

Dependent/Monitor:

Monitor kidney function

(BUN and creatinine)
labs as ordered by MD

Monitor BNP labs as

ordered by MD

An extensive amount of blood from the

heart gets pumped to the kidneys. If the
kidneys are not receiving adequate blood
flow to be perfused, they will not function
properly. If the kidneys are not functioning
properly, this may lead to excess fluid in the
body. Excess fluid then increases preload
and afterload which increases workload of
the heart. This can weaken the left ventricle
and compromise CO. Since this pt has ARF
and CHF, monitoring kidney function is
essential to assess for adequate renal
perfusion and also adequate fluid status
(NCP Gulanick/Myers p38/class notes).

Unmet. Pts BUN

and creatinine were
both elevated.

BNP is elevated with increasing filling

pressure (preload) and volume in the left
ventricle. An increased BNP indicates FVE
which is a clinical manifestation of CHF.
This pt was dx with CHF and had a BNP of
1840. After heart failure is diagnosed, BNP
is monitored to assess the effects of therapy.
Since this pt is receiving meds that increase
CO and decrease s/s of CHF, BNP should
be monitored to evaluate effectiveness of
treatment and fluid status. FVE increases
the workload of the heart d/t increased
afterload. Continuous stress on the left
ventricle will cause hypertrophy and
therefore impaired contractility (NCP
Gulanick/Myers p38/Lab tests and
Diagnostic Procedures).

Unmet. Pts most

recent BNP was
731 (but this was
significantly lower
than previous
draws).

15.

Pt and family will verbalize

understanding of meds and
their purpose by discharge

Teach:
Teach pt and family
about meds and their
purpose upon admission

By teaching the pt and family about the

medication regime, it provides them with
reasoning and understanding of meds. If the
pt and family understand why the meds are
prescribed, they will be more likely to
comply and perform the care needed for the
diagnosis. Since this pt has AFIB, CHF,
CAD, AAA, HTN, and
hypercholesterolemia, they have an
extensive cardiac hx and need to comply
with med to keep their health under control.
This will also improve CO by controlling
underlying problems (NCP Gulanick/Myers
p40).

Unmet. Pt was
discharged before
verbalizing
understanding. Pt
went to another
skilled nursing
facility where
teaching should
resume.