Planning/Implementation/Evaluation

Med/Surg Nursing Diagnosis: Risk for decreased cardiac output r/t irregular heart rhythm
Long-Term Goal: pt will maintain adequate cardiac output
Outcome Criteria

Interventions

Rationale

Evaluation

One outcome criteria

for each intervention.
Number each one.

Label each as
assess/monitor/independent/
dependent/teaching/collaboration

Answers why, how, what your interventions will help solve, prevent,

Evaluate the patient

outcome, NOT the
intervention

1. Pts lung sounds

will remain clear as
assessed qShift.

1.Assess- Assess lung sounds

qShift

1. Lung sounds should be clear anteriorly and posteriorly bilaterally.

If there is decreased cardiac output the blood may back up into the
lungs, thus causing adventitious lung sounds such as crackles.
Crackles reflect accumulation of fluid in alveoli due to impaired left
ventricular emptying. If this occurs it may be necessary to
administer a diuretic to help remove the extra fluid. This pt has a hx
of CHF and normally takes 80mg Furosemide qday at home. (P&P,
p. 503) This pt also has A-Fib which can lead to congestion of
pulmonary veins. This could cause an increase of fluid in the lungs
that could cause the pt to have crackles due to the extra fluid that
the decreased CO of A-Fib is unable to perfuse effectively to the
kidneys. (Gualanick, Myers)

1. Met

2. Pts BP will be
>90/>60 and
<150/<90 as
assessed q8h.

2. Assess- Assess BP q8h

2. This pt has a history of HTN. HTN is a risk factor for

cardiovascular diseases and effects. The heart has a decrease
ability to pump effectively when the BP is increased because it has
more resistance to pump against. Research shows that controlling
HTN increases longevity and helps prevent cardiovascular illness.
Blood pressure depends on cardiac output. Cardiac output is equal
to the heart rate times the stroke volume. The contraction of the
heart is what pushes the blood through the vessels. Blood pressure
should be about 120/80 when cardiac output is adequate. This
would indicate that the blood is properly perfusing throughout the
body. (Tabers Dictionary pg. 1170-1174)

2. Met

3. Pts intake will be

within 200ml of
output as assessed
qShift

3. Monitor- Monitor I&O qShift

3. This pt has a hx of CHF and non-pitting edema was noted on her

BLE during head-to-toe assessment. I&Os are often monitored in
patients with HF to detect the retention of fluids. A sign and
symptom of HF is edema, which is the retention of fluids in the
interstitial spaces. Monitoring I&O can help determine if a patient is
losing the fluid associated with HF or if they are holding on to it and
is an indicator of whether the HF is improving or worsening. Renal
insufficiency is often caused by decreased perfusion to the kidneys
(as 25% of blood flow in a healthy heart would go to the kidneys)

3. Unmet; pt was able

to toilet self and was
not using nuns cap in
toilet to allow for
monitoring of output.
Therefore I&O could
not be adequately
monitored

or lesson the stated problem specific to each patient.

by HF and monitoring I&O can help indicate how well the kidneys
are being perfused. (Tabers pg. 895, Lewis pg. 802, 803)

4. Pt will be
cardioverted to a
normal sinus rhythm
by discharge

4. Monitor- Monitor telemetry as

ordered qShift

4. Telemetry monitors the heart rate and rhythm. The heart rate is
directly related to cardiac output. Also, dysrhythmias may
contribute to a decreased cardiac output due to the fact that the
heart would not be pumping as efficiently to perfuse the body. This
pt was in A-Fib for her entire stay in the hospital, so it was very
important to monitor for other signs of adequate cardiac output
which could easily have been decreased by her irregular heart
rhythm. (Lewis pg. 821)

4. UnmetInterpretation of pts
telemetry indicated
that she was still in AFib upon discharge

5. Pts O2 sat will be

>92% on 2L O2 via
NC as assessed
qShift

5. Dependent-Administer 2L/min
O2 via NC continuously as
ordered by MD

5. Normal O2 sat should be between 95-100%. This pt has COPD

which will further increase her demand/need for additional O2. Any
change in the oxygen saturation of venous blood is an indicator of
decreased cardiac output. The pt is currently on 2L/min of O2 via
NC, with an O2 sat of 95% this additional oxygen supply improves
oxygen saturation and assists in meeting tissue oxygen demands of
the body and heart. By making oxygen more readily available to the
body and heart muscles the heart is able to pump more effectively
and improve cardiac output. (Lewis, p. 806)

5. Met: pts O2 sat was

95% on 2L/min O2 NC
when as assessed
qShift

6. Pts BNP levels will

be within 0-100pg/ml
when ordered.

6. Dependent- Evaluate BNP

levels as ordered by MD.

6. BNP levels correlate with the level of left ventricular dysfunction.

BNP is a neurohormone synthesized by the ventricles of the human
heart in response to increases in ventricular pressure and volume.
BNPs are hormones produced by the heart to promote venous and
arterial vasodilation, reducing preload and afterload. The level of
BNP in the blood increases when heart failure symptoms worsen,
and decreases when the heart failure condition is stable. Therefore
monitoring them is important when evaluating the effectiveness in
the treatment of HF. The pts initial BNP upon admission was
elevated at 346, which indicated worsening symptoms of HF. (Lewis
pg. 800-803, Nursing Central)

6. Unmet- Pts BNP was

346 pg/mL when
initially assessed with
admission labs on
11/18/14, no other labs
were drawn to assess
BNP by her discharge
on 11/22/14

7. Pt will lose at least

1lb/day as recorded
qDay

7. Monitor- Monitor pts weight

daily

7. Weight is the best indicator of fluid volume excess. A 1kg wt gain

indicates 1 liter of fluid retained in the body. Increased wt (2lbs in 2
days) may indicate a decreased cardiac output with retention of
fluids. This pt has CHF which is causing her to retain fluid, AEB
edema in BLE. An increase in wt gain would indicate that her output
has further decreased rather than improved and may show a need
for medication regimen change to improve her cardiac output in
order to decrease fluid retention and edema. (P&P, p. 983)

7. Unmet- pts chart

only noted weight on
admission. No other
daily weights were
recorded until her
discharge, but this
would be important for
the pt to do at home

8. Pt will be in semi
to high fowlers
position at all times

8. Independent- Place pt in semi

to high fowlers position at all
times

8. Placing the pt in semi-high fowlers with the legs in a horizontal

position or dangling at the bedside with increase the venous return
because of the pooling of blood in the extremities. During HF pts
have a decreased ability to pump the blood effectively and this
position will assist in getting the blood back to the heart effectively.
This position will also assist with breathing by allowing for increased
thoracic capacity, if the pt needs improved ventilation which she
does. This is also an appropriate intervention due to her COPD
which will promote adequate O2 intake from breathing and lung
expansion. (Lewis, pg. 803)

8. Met

9. Pts HR will remain

between 60-100bpm
as assessed qShift

9. Dependent- Administer
250mcg Digoxin (Lanoxin) PO
qday with lunch per MD order

9. Digoxin is a digitalis glycoside used in atrial fibrillation. It works

by increasing the force of myocardial contraction. My pt had Atrial
Fibrillation and needs the prolonging the refractory period at the AV
node and decreasing conduction through the SA and AV nodes. This
creates a positive inotropic effect and increases the cardiac output.
It also is significant to assess the apical pulse and if it is < 60 beats
per minute it must be held and the doctor must be notified (Davis,
p. 892)

9. Met

10. Pts BP will be

>90/>60 and
<140/<90 as
assessed after
administration of
Metoprolol

10.Dependent- Administer 50mg

Metoprolol PO BID per MD order

10. Metoprolol is a beta blocker used as an antianginal and

antihypertensive. It is used in ventricular arrhythmias and helps
slow the ventricular response by blocking the stimulation of beta,
(myocardial) adrenergic receptors. This in turn decreases blood
pressure and heart rate by decreasing myocardial oxygen demand.
This decreases cormobidity. It is necessary to monitor the heart rate
and blood pressure to safely administer Metoprolol. Metoprolol
helps the heart to beat more effectively to have an adequate
output. (Davis, p. 814)

10. Met

11. Pts BP will be

>90/>60 and
<140/<90 as
assessed after
administration of
Amlodipine

11. Dependent- Administer 5mg

Amlodipine (Norvasc) PO qDay
per MD order

11. This calcium channel blocker will inhibit the transport of calcium
to the myocardial and vascular smooth muscle cells. Since calcium
is needed in muscle contractions this will result in a decrease of
contractions; this promotes a decreased blood pressure and
increases coronary artery dilation. The increased blood flow to the
heart as well as the decreased workload to pump will improve
cardiac output. (Davis, p.156)

11. Met

12. Pts BP will be

>90/>60 and
<140/<90 as
assessed after
administration of
Lisinopril

12. Dependent- Administer 20mg

Lisinopril (Prinivil) PO qDay per
MD order

12. This ACE inhibitor blocks the conversion of angiotensin I to

angiotensin II (a vasoconstrictor). It promotes vasodilation which
will decrease afterload and also helps to diurese via the
suppression of aldosterone, helping to remove edema and improve
preload. The improvement of preload as well as the decreased
systemic vascular resistance will improve cardiac output of this pt.
(Davis, p. 176, Lewis, p. 807)

12. Met

13. Pt will meet with

PT/OT to discuss
requirements for
home before
discharge

13. Collaboration- Refer pt to

PT/OT before discharge

13. An individualized plan for this pt will help to establish

consistencies as well as helping the patient cope. PT/OT can discuss
and implement methods to help the pt maintain independence and
continue to perform ADLs by herself since she lives alone. She
does have a family support network, so it may also be appropriate
to include the family in the plans for discharge.

13. Met

14. The pt will

verbalize 3 SE of
each medication
after teaching

14. Teach- Teach pt side effects of

medication

14. The medicines that this pt is on include beta blocker, ACE

inhibitors, anticoagulants, lipid lowering agents and digitalis
glycoside. It is important that the pt knows what each medication is
doing for them. The expected side effects, and side effects they
need to report to the doctor; as well as the need to not abruptly
discontinue them. These medications regulate the heart rate, blood
pressure and try not to maintain blood flow through the arteries but
decreasing plaque and thinning the blood. Abruptly stopping these
could cause decreased cardiac output. (Ackley & Ladwig, p. 205)

14. Met

15. Pt will verbalize 4

signs and symptoms
of worsening HF
before discharge

15. Teach- Teach pt the signs and

symptoms of worsening HF before
discharge

15. It is important to provide the pt with signs and symptoms of HF

exacerbations. The nurse should review the S/S with the pt and
family (if applicable) and provide them with a clear action plan of
what to do should these symptoms occur. The information
regarding exacerbation symptoms is important in the treatment of
HF and the reduction of hospitalizations. Some symptoms a patient
should report is increase in shortness of breath, inability to perform
ADLs, weight gain greater than 2lbs in 2 days, pitting edema in the
sacrum or extremities, and confusion. (Lewis, pg. 812)

15. Met