CARE PLAN DECREASED CARDIAC OUTPUT

THE NURSING PROCESS: NURSING CARE PLAN

NURSING DIAGNOSIS ­ 2

(Problem; Etiology; Signs &
Symptoms)

P­ Decreased Cardiac Output R/T E­ Atrial Fibrillation and Mechanical
Ventilation

AEB S – Client on mechanical ventilation.
Albumin 1.1 – 2/4/14 – low osmolality in blood – third spacing.
Atrial Fibrilation
Sluggish Pupil response
Blood pressure 97/39
Heart Rate 54
Peripheral pulses diminished

PLANNING
____________________________________________________________________________________

Client Goal: Client will not have decreased Cardiac Output

Outcome Criteria

Nursing Interventions

Rationale for Nursing Interventions

(Measurable evidence that will demonstrate that client goal was met)

(Assess; Do; Teach)

(Author and page number)

ASSESS

1) Client’s heart rate/rhythm will remain in desired limits while at
DGH.

1)

Assess heart rate, rhythm and sounds q 2h.

1)

Without a normal rate and regular rhythm, the heart does not perform efficiently as a pump to circulate oxygenated blood producing symptoms related to the hemodynamic effect they cause, such as decreased cardiac output (Pellico, p. 461).

2)

Symptoms of decreased cardiac output may include dyspnea, orthopnea, paroxysmal nocturnal dyspnea,
Cheyne­Stokes respirations, fatigue, weaknes, third and fourth heart sounds, crackles in lunchs and positive hepatojuglar reflex (Ackley & Ladwig,
p. 198).

3)

Client may be receiving cardiac glycosides and the potential for toxicity is greater with hypokalemia, which is common with imbalanced fluid volume
(Ackley & Ladwig, p. 200).

4)

The nurse observes for the benefits and adverse effects of medications and also manages administration carefully, so that a constant serum blood level of the medication is maintained (Pellico, p.

2) Client will maintain electrolyte and ABG values within normal limits while at DGH.

2)

3) Client’s