PLANNING/IMPLEMENTATION/EVALUATION (See Grading Rubric for NCP Criteria)

Nursing Diagnosis: Risk for decreased cardiac output related to ventricular arrhythmia
Long Term Goal: Patient will maintain adequate cardiac output
Outcome Criteria
One outcome criteria for each
intervention. Number each one.

Interventions
Label each intervention as:
Assess/Monitor/Independent
Dependent/Teaching/Collaboration

Rationale

Evaluation

Answers why, how, what your interventions will Evaluate the patient
help solve, prevent or lessen the stated problem outcome NOT the
specific to this patient.
intervention

Assess/Monitor

1. Pt will not have peripheral

edema upon assessment
q4h

1. Assess peripheral edema Edema is swelling caused by excess fluid

q4h

trapped in your body's tissues. Although

edema can affect any part of your body, it's
most commonly noticed in the hands, arms,
feet, ankles and legs. The patient has CHF
which means the hearts lower chambers
lose their ability to pump blood effectively.
This causes the blood to back up in your
legs, ankles and feet (as well as other
areas), causing edema. The patient also has
acute on chronic kidney disease which
causes extra fluid and sodium in circulation
which causes edema. The edema
associated with kidney disease usually
occurs in your legs and around your eyes.
Excess peripheral edema may be improved
by taking a diuretic to decrease Na and

Met, plan ongoing

2. Patient will be free of

adventitious lung sounds
upon assessment q4h

3. Pt will have normal S1

and S2 sounds heard
without S3, S4 present

2. Assess lung sounds q4h

water via excretion such as Lasix. This

decreases blood volume which decreases
preload and afterload, improving cardiac
output.

Met, plan ongoing

Crackles reflect fluid accumulation

secondary to impaired left ventricular
emptying. Pleural effusions may also be the
result of left ventricular failure. An increase
in crackles or absent breath sounds are
cause for concern of decrease cardiac
output. The patient has chronic heart failure
which increases the likelihood that fluid will
accumulate in the lungs. The cxr showed
mild pulmonary vascular congestion with
basilar atelectasis. This means there is
engorgement of pulmonary vessels with
transudation of fluid into the alveolar and
interstitial spaces. This extra fluid makes it
harder for the heart to pump and also
indicates an ineffective pump. If the heart
does not pump adequately enough, there
will not be enough output to perfuse the
kidneys that would then excrete the extra
Met, plan ongoing
fluid from the body, thus keeping it in the
3. Assess heart sounds q4h vascular system making it harder. Clear L/S
are indicative of the extra fluid moving away
and an adequate cardiac pump.
S1 and S2 are the normal lub-dub heart
sounds heard during auscultation. Hearing
an S3 would indicate reduced left ventricular
ejection and blood sloshing within the walls

4. HR will be between 60100 bpm, BP 90/50130/80 mmHg, 12-20

resps/min, temp 96.899.5, and O2 sat 93100%

5. Pt will have urine output

of at least 240cc in 8
hours upon assessment
qshift

4. Monitor vital signs q4h

of the heart. S4 signifies reduced left

ventricular compliance due to hypertrophy
which impairs filling. Murmurs signify
abnormal flow of blood through the valves.
The MD would need to be notified of
abnormal S3 and S4 sounds being heard.

Partially met, the

pts BP was low at
96/48, however
after
discontinuation of
the Lasix, the pts
Many patients with decreased cardiac output BP improved to
have tachycardia, decreased BP, decreased 107/65. Plan
ongoing
O2 sat, and increased RR. Older patients

have a reduced response to catecholamines

resulting in a decreased response to
decreased cardiac output with less increase
in HR. The patient is experiencing PSVT
which causes episodes of tachycardia where
the heart cannot pump or fill adequately due
to the elevated heart rate. This can influence
or worsen heart failure. Changes evidencing
decreased cardiac output would first be
seen in HR, BP and RR. If abnormals in vital
signs are seen, interventions may be made Partially met, pt
had voided 150 cc
like applying/increased O2, giving a
medication like adenosine, nitroglycerin, or urine, however not
a full shift was
5. Assess urine output qshift calling the MD for further direction.

spent with her. Will

continue to
The renal system compensates for low
monitor, plan
blood pressure and decreased perfusion by
ongoing
retaining Na and water. Decreased urine
output or oliguria is a classic indicator of
decreased cardiac output. The patients
BUN and Cr are both within normal limits
and GFR does not show any acute disease.
The patient is ambulatory to the bathroom
and voids in the toilet in which her urine is

6. Pt will not use accessory

muscles to breathe upon
assessment with
interactions

7. Pt will not have a weight

gain of more than 2
pounds in 2 days upon
assessment daily

6. Assess use of accessory

muscles with interations

7. Weigh pt daily

measurable with a specipan. She should

Met, plan ongoing
have at least 240cc urine output in 8 hours
to prove adequate renal perfusion by the
heart. If there is less than 240 cc, the MD
should be notified to receive further
direction.
Heart failure means the heart is not pumping
enough blood to keep the organs alive.
Since it is unable to pump the blood fast
enough, the blood on the way to the heart
gets backed up in the veins. Reduced blood
flow to the kidneys results in water retention.
You end up with fluid in the lungs and
edema on the body. The use of accessory
muscles indicates increased work of
breathing and should be noted on
assessment. These muscles include the
Unmet, pt was not
sternocleidomastoid, upper trapezius,
weighed during our
pectoralis major, and others. If use of
accessory muscles is noted, the nurse may care. Plan ongoing
also auscultate the lung sounds, administer
a diuretic to help remove fluid, administer
oxygen, and notify the MD of the pts
distress.
Heart failure happens when your heart
muscle isn't pumping enough blood to the
rest of your body. Because the heart isn't
pumping as it should, fluids can start to build
up. This fluid presents as peripheral edema,
crackle sounds in the lungs, jugular vein
distention and more. If there is more than a
2 pound weight gain in 2 days, the MD
should be notified because that signifies that Unmet, patient had

8. Pt will not have abnormal

ECG changes including
tachycardia, pvcs, or
pacs

treatment is not effective enough for proper

cardiac function. A dose of Lasix may need
to be increased and measures can be made
such as positioning that will help blood flow
8. Monitor ECG for changes back to the heart, improve preload and
afterload.
q2h

9. BNP will return to normal

range of 0-100 pg/mL by
discharge

9. Monitor BNP level as

episodes of PSVT
with HR of over
122 with pvc
during our care.
Plan ongoing

The patient has PSVT which involves

episodes of tachycardia triggered by pacs or
pvcs. When the heart is beating this fast
(upwards of 150 bpm at times), the heart
does not have enough time to adequately
fill, and therefore adequately pump blood to
the rest of the body, leading to heart failure.
The heart becomes overworked and can
become enlarged. Noticing that the HR is
elevated on the ECG allows for interventions
to be made such as calling the MD who may
Unmet, BNP was
prescribe a medication such as adenosine.
788 upon
When the pt was experiencing a HR of 122,
admission and no
the primary RN called the MD to give the
other labs have
dose of Diltiazem early to lower the heart
been drawn. Plan
rate. Managing the heart rate allows for
better cardiac output and better perfusion to ongoing
the tissues.

ordered by MD
BNP is elevated with increased filling
pressure, volume, and stretch in the
ventricles. BNP increases Na excretion,
decreases blood volume, decreases
afterload and yield increased cardiac output.
The patients BNP is elevated to 788,
signifying heart failure. Lowering the BNP to Met, plan ongoing
an acceptable level of 0-100 will reduce

10. Pt O2 sat will be 93100% at all times upon

assessment

11. Pt BP will be between

90/50-130/80 mmHg qd
and upon assessment

stress on the heart, and signify an increase

in cardiac output. If the BNP is seen to be
rising or not improving, the MD may
prescribe a new medication or increase a
dose of something like Lasix that would
improve heart failure and improve cardiac
10. Administer O2 as needed output.
to keep sat > 93% at all
times
Patients with heart failure may not be able to
respond adequately to increased O2
demand of the heart. O2 supplementation is
necessary in these cases. The patient did
not require supplemental O2 while in my
care but her O2 sat should be monitored in Partially met: Pt BP
the case that her heart failure worsens and was 96/48, Lasix
her saturation drops. Her PSVT is still not
was DCd, BP
under control so her heart failure can be
improved to
worsening. If the O2 sats drop low, O2
supply to the heart and other body tissues is 107/65. Plan
decreasing which decreases cardiac output. ongoing
Keeping the heart oxygenated increases
cardiac output.
11. Administer furosemide
20mg/2mL soln IVP qd
Diuretic such as furosemide will reduce
circulating blood volume by increasing Na
and water excretion. The end effect is
decreased BP and decreased edema. This
decreases preload and afterload and
decreases the workload on the heart. The
patient has HF which tends to increase
edema and decrease kidney perfusion
leading to retention of fluids. Removing
Met, plan ongoing
excess fluid will decrease workload of the
heart, preload, afterload and increase

cardiac output. The patients blood pressure

was low at 96/48 upon first assessment in
the morning, therefore the doctor temporarily
discontinued the Lasix to allow the blood
pressure to increase. At 11:15 the pts blood
pressure was improved to 107/65.

12. Pt potassium level will be

between 3.6 and 5.2
mmol/L as assessed after
administration of IVF with
KCL at 100cc/hr

12. Administer D NS with

KCL 40 meq/1000 mL at
100 mL/hr

Upon admission to the emergency room the

patient was being treated with Lasix which
inhibits reabsorption of Na and Cl from the
loop of Henle and distal renal tubule. It
therefore causes an increase in the
excretion of water, Na, Cl, Mg, and K.
Met, plan resolved
Potassium is essential for proper electrical
conduction of nerve impulses in smooth
muscle such as the heart. These IV fluids
help to replace the amount of potassium lost
due to diuretic use and maintain adequate
conduction and proper cardiac output.

13. Pt will verbalize 5 signs of

decreased cardiac output
that require medical
attention prior to
discharge

13. Teach the patient signs of Signs and symptoms of decreased cardiac

decreased cardiac output output are varied and can be attributed to

requiring medical attention many things if one is not specifically looking
for them. The patient should be taught that
prior to discharge
changes in resp rate, depth, effort signal
worsening lung function that is likely due to
congestion from inadequate cardiac output.
Other symptoms to watch for include urine
output of less than 240 cc in 8 hours,
extreme fatigue/weakness, hypotension,
tachycardia, cool or clammy skin, increased
edema, increase in daily weight (2lb gain or
more in 2 days), all of which require the

Unmet, smoking
cessation was not
discussed, plan
ongoing

attention of a health care provider. Knowing

these signs and getting medical help when
needed will help to minimize complications.

14. Pt will verbalize a plan on

how to quit smoking prior
to discharge after
teaching about smoking
cessation qd

14. Teach the patient about

smoking cessation qd

15. The patient will verbalize

the importance of a
cardiac diet and what
kinds of
foods/substances she
must avoid daily

15. Teach the patient about

proper cardiac diet qd

Smoking-related coronary heart disease

contributes to congestive heart failure.
Toxins found in the blood from smoking
cigarettes contribute to the development
of atherosclerosis, which is a progressive
hardening of the arteries caused by the
deposit of fatty plaques and the scarring and
thickening of the artery wall. Inflammation of
the artery wall and the development of blood
clots can obstruct blood flow and cause
heart attacks or strokes. It also causes
increased resistance that the heart must
pump blood against so the heart is
Partially met: pt
overworking and become enlarged leading
to heart failure. The patient states she is an understands she
must avoid
occasional smoker since she was in her
teenage years. Teaching her about how it is caffeine, fatty
foods, and high
not too late to stop smoking and
sodium but
encouraging her to make a plan to stop
smoking can help her to quit and improve
reasons as to why
her cardiac output.
were not discussed

in depth. Plan
People with heart failure may improve their ongoing
symptoms by reducing the amount of
(sodium) in their diet. Sodium is a mineral
found in many foods. Eating too much salt
causes the body to keep or retain too much
water, worsening the fluid build-up
associated with heart failure that can cause
edema and adventitious lung sounds with
shortness of breath or activity intolerance.

Following a low-salt diet also helps control

high blood pressure by decreasing the
amount of circulating volume. Pts with heart
failure should consume no more than 2,000
mg of salt per day. The pt should also avoid
caffeine and other stimulants because it can
aggravate the pts PSVT and result in
tachycardia and palpitations. The pt should
also opt for a low fat diet to decrease
cholesterol and the amount of plaque
buildup in the arteries which would improve
cardiac output.