NURSING CARE PLAN

ASSESSMENT
Subjective Cues: N/A Objective Cues: Generalized paleness noted Irregular rhythm of pulse noted

NURSING DIAGNOSIS
Decreased Cardiac Output related to altered heart rate and rhythm 2o MI

RATIONALE

PLANNING
STG: At the end of 30min Nursing Interventions, the client will be able to: Demonstrate hemodynamic stability (blood pressure and cardiac output) by 20% 30% as revealed in the cardiac monitor LTG: At the end of 8-hour Nursing Interventions, the client will be able to: Demonstrate hemodynamic stability (Blood pressure and cardiac output) by 31%-80% as revealed in the cardiac monitor Manifest absence of angina

NURSING ACTION
Assessed for and document the ff: o Mental Status

RATIONALE
Cerebral perfusion is directly r/t cardiac output and aortic perfusion pressure and is influenced by hypoxia and electrolyte and acid-base variation Crackles may develop r/t alterations in MI Hypotension r/t hypoperfusion, vagal stimulation, dysrhythmias, or ventricular dysfunction may occur Bradycardia may be present because of vagal stimulation or conduction disturbances r/t area of MI Urine output <0.5mL/kg/hrmay reflect reduced renal perfusion and glomerular filtration as a result of reduced cardiac output Decreased may indicate a decreased cardiac output -MSN, Black and Hawks, Vol. 2, 7th edition Facilitate oxygenation -NANDA, Doenges, Moorhouse, Murr, 11th edition

EVALUATION
At the end of 8-hour Nursing Interventions, the goal was partially met as evidenced by: PR = Cardiac monitoring revealed slight disturbance

Occlusion in the artery Decreased blood supply Decreased venous return Decreased amount of blood expelled by ventricles Decreased cardiac output

o Lung sounds o Blood Pressure

PR =

o Heart Sounds

Endorsed to the next shift NOD for further interventions and revisions of NCP for continuity of care

o Urine Output

o Peripheral Perfusion

Kept client on bed in Semi-fowlers and administered high flow O2 via nasal cannula

 Monitored and assessed angina for type, severity and duration

Administered beta-blockers and inotropin agents and monitored their effects

Angina indicates myocardial ischemia, which may decrease cardiac ouput -MSN, Black and Hawks, Vol. 2, 7th edition To determine effects of therapy