Common Nursing Diagnoses Decreased Cardiac Output

Underground Fat Loss Manual

Best Weight Loss Programs That Work

Get Instant Access

Related to: Mechanical factors—alterations in preload; alterations in afterload; alterations in inotropic function of heart.

Defining Characteristics: Variations in hemodynamic readings (BP, CVP); hypovolemia; jugular vein distention; oliguria; decreased peripheral pulses; cold, clammy skin; crackles; dyspnea (specify).

Related to: Electrical factors—alterations in rate; alterations in rhythm; alterations in conduction.

Defining Characteristics: Arrhythmias, ECG changes, bradycardia, changes in contractility resulting from preload or afterload abnormalities (specify).

Related to: Structural factors.

Defining Characteristics: Murmurs, fatigue, cyanosis, pallor of skin and mucous membranes, dyspnea, clubbing, activity intolerance (specify).

Goal: Client will experience increased cardiac output by (specify date and time to evaluate).

Outcome Criteria

V Client's BP, heart rate, and respirations will return to or remain within (specify appropriate ranges for each).

V Absence of cardiac dysrhythmias.

V Skin color and mucous membranes pink; tolerates activity (specify level).

NOC: Cardiac Pump Effectiveness

INTERVENTIONS

Assess cardiac output by monitor—heart rate (apical and peripheral pulses) for 1 minute, noting quality, rate, rhythm, intensity; pulse deficiency; use radial site with gentle palpation in child over 2 years of age, and use apical site with stethoscope and correct size diaphragm in infant and young child; grade pulse on a range from 0 to +4 (specify).

Assess blood pressure using proper size cuff; diaphragm on stethoscope of proper size; and aneroid or mercury instrument, Doppler method, or electronic device. Approximate cuff width sizes are 4 to 6 cm for infant, 8 to 9 cm for child 2 to 10 years of age; BP cuff bladder should completely encircle extremity circumference and cuff width should cover 2/3 of upper arm/thigh. Take BP of infant with infant supine; take child BP with child sitting and arm supported at heart level; sites for BP determinations may be (radial), leg (popliteal), or ankle (dorsalis pedis) (specify).

Assess BP when infant/child is at rest (give expected range).

Assess existence of dysrhythmias per ECG tracings.

RATIONALES

Cardiac output is the amount of blood pumped from the heart in 1 minute and is determined by multiplying the heart rate by the stroke volume (amount of blood ejected with 1 contraction), which depends on heart contractility, preload and afterload; pulse easily obliterated by compression.

Doppler method transmits audible sounds through a transducer in the cuff caused by ultrasound frequency caused by blood flow in the artery; the use of oscillometry transmits pressure changes through the arterial wall to the pressure cuff which are detected by an indicator that prints out the readings for BP and pulse.

Crying or other activity can increase BP 5 to 10 mm Hg; BP elevations that are considered abnormal are: >110/70 in 3 to 6 year olds, >120/75 in 6 to 9 year olds, and >130/80 in 10 to 13 year olds.

Device that measures and records the heart's electrical activity and provides information about heart rate and rhythm, hypertrophy, effects of electrolyte imbalances, conduction problems and cardiac ischemia.

Administer cardiac (specify drug, dose, route, and times as ordered) glycosides, vasodilators; monitor for digoxin toxicity by symptoms of anorexia, nausea, vomiting, bradycardia, arrhythmias and digoxin level within 0.8 to 2.0 mcg/L range (therapeutic level) potassium level; take apical pulse for 1 minute before administering digoxin, and withhold if pulse below desired level for age of child.

Position for comfort and chest expansion in Fowler's, provide quiet environment, pace any activity to allow for rest.

Monitor temperature for increases q 4 hours.

Attach cardiac monitor to infant/ child if prescribed.

Inform about heart condition's effect on pulse and blood pressure, and the need for rest and reduction of stress.

Instruct in correct taking of peripheral and apical pulses and when to take them.

Instruct in administration of cardiac glycoside (specify form, dosage, how to take, frequency and time of day), to give 1 hour before or after feedings and not with food, to avoid second dose if child vomits, to avoid making up missed doses when less than 4 hours have passed, and to maintain careful records of administration and effects or adverse signs/symptoms.

Inform to report changes in pulse, blood pressure, digoxin toxicity, change in breathing pattern, edema, presence of infection.

Instruct in application, settings and alarms in use of cardiac monitor.

NIC: Cardiac Care Evaluation

(Date/time of evaluation of goal)

Vasodilators decrease pulmonary and systemic vascular resistance, which decrease afterload and BP; cardiac glycoside strengthens and decreases the heart rate, which decreases the workload of the heart by more efficient cardiac performance; decreased potassium level enhances risk for digoxin toxicity.

Promotes ease of breathing and rest; reduces stress and workload of the heart.

Pulse increased at rate of 8 to 10/ minute with every degree of elevation on F scale.

Reveals changes in heart rate and respirations.

Provides information to promote compliance with medical regimen and realization of importance of reducing workload of the heart.

Encourages caretaker, parents to correctly monitor changes in heart function.

Ensures correct administration of cardiac glycoside to prevent toxicity and improve cardiac performance.

Allows for prompt treatment to prevent complications like dysrhythmias or heart failure.

Monitoring may be advised and prescribed for cardiac and respiratory changes.

(Has goal been met? Not met? Partially met?) (What are BP, heart rate, and respirations?) (Describe cardiac rhythm.)

(What color are skin and mucous membranes? What activity does the child tolerate?) (Revisions to care plan? D/C care plan? Continue care plan?)

EXCESS FLUID VOLUME

Related to: Compromised regulatory mechanisms.

Defining Characteristics: (Specify: periorbital usually but may be dependent on weight gain, effusion, shortness of breath, orthopnea, crackles, change in respiratory pattern dyspnea, tachypnea, oliguria, specific gravity changes, altered electrolytes.

Goal: Client will return to a state of fluid balance by (date/time to evaluate).

Outcome Criteria

V Intake equals output.

V Lung sounds clear.

V Absence of periorbital edema.

V (Specify others if appropriate for client.) NOC: Fluid Balance

INTERVENTIONS

Assess presence of edema in periorbital tissue or dependent areas, such as extremities when standing; in sacrum and scrotum when in lying position; or generalized in an infant; neck vein distension in child (specify frequency).

Weigh (specify: daily BID or as needed) on same scale, at same time, and with same clothing.

Assess for plueral effusion by presence of dyspnea, tachypnea, crackles, orthopnea, acites; for hepatomegaly by measuring abdominal girth (specify frequency).

RATIONALES

Increased sodium and water retention result in increased systemic vascular pressure and fluid overload, which lead to edema; gravity determines the site of dependent edema.

Weight gain from fluid retention is an early sign of fluid retention.

Indication of gross fluid retention which causes impaired organ function (pulmonary and system venous congestion) is associated with some cardiac or renal

Assess for oliguria, increased specific gravity, electrolyte imbalances.

Administer diuretic therapy early in the day (specify drug, dose, route, and times for client), and monitor resulting diuresis by accurate I&O and weight.

Note and document I&O (including losses from breathing and diaphoresis) and intake from all fluids IV or orally taken with medications and meals (if child not toilet trained, weigh diaper to calculate output at 1 gm = 1 ml).

Restrict fluid intake as ordered

(specify amount calculated for this child); schedule over 24 hours with most given during the day hours; use small cups and allowing older child to keep track of daily amounts.

Limit sodium intake as ordered by removing salt shaker, foods high in salt.

Maintain bed rest, and position and support edematous body parts; change position (q 2h or specify) provide sheepskin, egg crate mattress.

Instruct caregiver in taking weights, noting and reporting gains and losses; and in measuring I&O, and reporting excessive outputs from diuretic therapy or decreases in comparison or intake.

Instruct caregiver in correct administration of diuretic early in the day for a child (specify amount, frequency, side effects, and amount of output to expect in relation to intake).

Instruct and assist caregiver to schedule fluid intake over 24 hours, with major portion administered during day hours.

NIC: Fluid Management conditions.

Indicates decreased renal perfusion, which activates the renin-angiotensin and aldosterone mechanism, resulting in water, sodium, and potassium retention.

Diuretics prevent reabsorption of water, sodium and potassium by tubules in the kidneys, resulting in excretion of excess.

Intake and output ratio should normally be 2:1 or 1 to 2 ml/kg/h.

Supports possible need for additional loss of fluid based on age and using possible limit of 65 ml/kg/24 hrs as a guideline.

Sodium intake is necessary for normal growth and development, and to offset diuretic therapy.

Protects and supports edematous parts from pressure and trauma.

Monitors weight to determine fluid accumulation and I&O to prevent imbalances (fluid overload or dehydration).

Promotes excretion of fluid to prevent accumulation.

Promotes compliance if fluids are restricted.

Evaluation

(Date/time of evaluation of goal)

(Has goal been met? Not met? Partially met?)

(Specify intake and output and time frame.)

(Are lung sounds clear?)

(Is there any periorbital edema?)

(Provide data released to other outcomes criteria that were identified.) (Revisions to care plan? D/C care plan? Continue care plan?)

INEFFECTIVE TISSUE PERFUSION: (CARDIOPULMONARY, CEREBRAL, GASTROINTESTINAL, RENAL, PERIPHERAL)

Related to: Interruption of arterial or venous flow, exchange problems, hypovolemia.

Defining Characteristics: (Specify: Cardiopulmonary—BP and pulse changes, dyspnea, tachypnea, changes in ABGs, cyanosis, changes in cardiac output, ventilation perfusion imbalances, crackles;

Cerebral—changes in mentation, restlessness, lethargy;

Gastrointestinal—vomiting, inability to digest and absorb nutrients, gastric distention; Renal—oliguria, anuria, periorbital edema, electrolyte imbalance; Peripheral—skin cold, mottled, or pale; decreased peripheral pulses). Goal: Client will exhibit effective tissue perfusion by (date/time to evaluate). Outcome Criteria

V Based on specific defining characteristics. Specify for client: (ABG values—specify ranges).

V Client is alert, not restless or lethargic.

V Bowel sounds present, abdomen soft, nondistended.

V Skin warm, pink, and dry, without edema. NOC: Tissue Perfusion

INTERVENTIONS

Assess organ functional abilities in relation to disease and its effect on a particular system (specify how).

Assess pulse, blood pressure, presence of peripheral pulses, capillary refill time, skin color and temperature; oxygenation saturation as measured by pulse oximetry; urinary output, mentation, anorexia, gastric distention (specify when).

Provide O2 by hood, cannula, or face mask, depending on age and at rate determined by ABGs as ordered (specify route and rate).

Administer vasodilator, cardiac glycoside as ordered (specify drugs, doses, routes, and times).

Position change q 2-4h (specify) to avoid pressure on susceptible body parts, perform ROM if needed.

Position in Fowler's at height of comfort if respiratory status compromised by pulmonary perfusion.

Inform caregiver of causes of decreased circulation and its effect on body organs.

Demonstrate positions that enhance comfort and circulation, such as cardiac chair or infant seat (specify), which alleviate pressure on body parts; use of pillows to maintain Fowler's position.

Inform caregiver to avoid tight and restrictive clothing, such as belts, elastic waists on pajamas, diapers.

NIC: Cardiac Care Evaluation

RATIONALES

Interrelationships of systems cause an overlapping of signs and symptoms associated with tissue perfusion causing changes in elimination, oxygenation, nutrition, and mental function.

Provides information about cardiac output, which, if decreased, will reduce blood flow and tissue perfusion.

Provides oxygen to organs for proper functioning.

Promotes cardiac output and slows and strengthens heart rate for a more efficient pump action and increased return flow of blood to the heart and decreased heart workload

Promotes circulation and prevents breakdown of tissue from further perfusion decreases associated with pressure.

Decreases blood volume returning to heart by pooling of blood in lower dependent parts of the body.

Promotes understanding of condition and risk to organ function.

Promotes comfort and prevents tissue breakdown.

Constricts circulation.

(Date/time of evaluation of goal)

(Has goal been met? Not met? Partially met?)

(What are ABG values?)

(Is client alert, not restless or lethargic?)

(Are bowel sounds present? Is abdomen soft and nondistended?)

(Specify cc/hr of urine output/time frame.)

(Is skin warm, pink, and dry, without edema?)

(Revisions to care plan? D/C care plan? Continue care plan?)

COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved.

KARLA L. LUXNER, RNC, ND

COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved.

STATIRef Online Electronic Medical Library

0-7668-5994-0

• Publication City:

Clifton Park, NY

• Publication Year:

2005

Thomson Delmar Learning

Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005)

• Electronic Address:

http://online.statref.com/document.aspx?fxid = 123&docid = 7

DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 2 - CARDIOVASCULAR SYSTEM CHAPTER 2.0 - CARDIOVASCULAR SYSTEM: BASIC CARE PLAN

Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates

Customer Service Send Us Your Comments User Responsibilities

800.901.5494 Training Center

What's New

Was this article helpful?

0 0
Weight Loss Enigma

Weight Loss Enigma

Finally Revealed The Revolutionary & Miraculous Weight Loss Secrets! Discover How to Command Those Unwanted Pounds To Take A Hike, So That You Can Get Into Shape & Lose Weight Easily Just Like You Dream Of In Just A Matter Of Weeks! You're About to Discover The Insider's Fat Burning Diet Tips to Easily Shed Off Those Extra Pounds And Obtain a Lovable Shape In No Time Flat!

Get My Free Ebook


Responses

  • Panu
    What goals should be met for decreased cardiac output?
    6 years ago

Post a comment