Cardiac Careplan-Katie Love Nursing Diagnosis: Decreased Cardiac Output r/t decreased vascular volume secondary to third spacing

as evidenced by pitting edema +4, BP 84/50, urine output of 200mls in 8 hrs Long term goal: Pt will regain adequate cardiac output

Intervention 1.Assess HR q4h and prn

Rationale

Outcome Criteria

Evaluation 1. Met Pt's pulse remained between 60-100 bpm

1. Heart rate is directly 1. Pt's HR will be between 60proportional to cardiac output. 100 as assessed q4h An adult HR is normally 60-100 bpm. Cardiac output=SVxHR. Stroke volume is the amount of blood pumped by the heart in one contraction. Not enough circulating volume may increase HR to compensate for lack of blood volume. When there is a decreased cardiac output there is an increased SNS stimulation that increases the HR. This pt had acceptable pulse parameters, but has a pacemaker to keep the HR beating above 60bpm, and takes digoxin to slow and strengthen the heart. (Lewis 1686)

2. Assess pulse oximetry q4h and 2. A pulse oximetry reading 2. Pt's pulse oximetry will be prn determines the amount of >93% as assessed q4hrs hemoglobin in the blood that is saturated with oxygen. The amount of oxygen transported around the body is determined mainly by the degree to which hemoglobin binds to oxygen, hemoglobin concentration, and cardiac output. This pt had decreased cardiac output because fluid was in an interstitial space from fluid shift from vascular space so that circulating blood volume was decreased. This pt had an O2 sat of 93% on 5 liters of oxygen. Decreased cardiac output is directly correlated to decreased oxygenation. (NDH 201) 3. Assess BP q4h and prn

2. Unmet pt's pulse oximetry was 92% and required 5liters of oxygen

3. Blood pressure is the pressure 3. Pt's BP will trend towards 3. Unmet Pt's blood pressure was exerted by circulating blood 120/80 as assessed q4h by end of as low as 84/50 upon the walls of blood vessels. clinical weekend. This pt had decreased cardiac output because fluid was in interstitial spaces. Fluid shift from vascular space decreasing circulating blood volume. A decrease in volume of blood flowing through the blood vessels will decrease pressure exerted on the walls of blood

vessels decreasing the blood pressure. (Lewis 1686) 4. Assess lung sounds q4h and prn 4. Change in shift of fluids may leak fluid from vascular space into the interstitial space. Fluid may move into the alveoli and clinical symptoms such as rhonchi and crackles may be present. (Lewis 1687) 4. Pt's lung sounds will be clear bilat before discharge 4. Unmet pt's lung sounds had wheezing and rhonchi

5. Assess skin color and temperature q4h and prn

5. Cool clammy skin is 5. Pt's skin will remain pink and secondary to compensatory warm as assessed q4h and prn increase in SNS and low cardiac output. A decreased cardiac output may cause skin to be pale and mottled. A decrease in circulating volume would decrease the blood reaching peripheral tissue. Warm, pink, skin indicates blood flow is reaching the tissues perfusing them with oxygen. (Lewis 778)

5. Unmet pt's skin color remained normal for pt (tan) but skin was cool

6. Monitor daily weight every day 6. Accurate daily weights 6. Pt will not gain more than 2lbs 6. Unmet pt gained 3lbs in 2 days provide the easiest measurement in 2 days of fluid volume status. An increase of 1kg 2.2lbs is equal to

1liter of fluid retention. It is important to weigh the pt on the same scale, clothes, and same time of day to obtain an accurate reading. (NDH 201)

7. Monitor LOC q4h and PRN

7. This pt had decreased cardiac 7. Pt will remain alert and output because fluid was in the oriented x 3 as assessed q4h and interstitial spaces which shifted prn fluid from vascular space so that circulating blood volume was decreased. The decrease in volume and decreased BP would not provide adequate blood flow to cerebral tissue. A decrease in cerebral circulation may cause pt to display signs such as restlessness, confusion, decreased attention, and memory loss. (Lewis 801)

7. Unmet pt was disoriented to time, and had intermittent confusion

8. Monitor intake and output every shift

8. Decreased cardiac output 8. Pt's urinary output will be results in decreased perfusion to greater than <30 ml/hr as the kidneys and decreased urine assessed prn output. In this pt fluid leaked from the vascular system into the interstitial spaces. We would like to see urinary output of <30 ml/hr (Lewis 1012)

8. Unmet Pt had urinary output of 200ml/8hr

9. Monitor for symptoms of heart 9. Symptoms of heart failure failure every shift include dyspnea, orthopnea, paroxysmal nocturnal syspnea, Cheyne-stokes respirations, fatigue, crackles in the lungs, edema. When the heart is not having cardiac output heart failure can occur. (NDH 198)

9. Pt will not have signs and 9. Unmet Pt displayed signs of symptoms of heart failure 3 days heart failure with elevated BNP, after admission adventitious lung sounds, and pitting edema

10. Monitor Albumin levels when 10. Albumin is the largest 10. Pt's albumin level will be drawn daily component of plasma proteins between 3.4-5 by end of clinical and aides in maintaining weekend colloidal osmotic pressure within the blood. Loss of albumin leads to decreased oncotic pressure. Fluid will leak from the intravascular space causing edema. (saunders Nursing guide to lab and diagnostic tests pg. 545)

10. Unmet pt's albumin level was 1.6