International Journal of
Nursing Terminologies and Classifications
Special Report ijnt_1172 23..32
Nursing Diagnoses and Interventions for a Child
with Dilated Cardiomyopathy Requiring
Intra-aortic Balloon Pump Support—Case Report
Juliana de Lima Lopes, RN, MSc, Silmara Meneguim, RN, MSc, PhD,
Claudia Cristina Soares Muniz, RN, MSc, PhD, and Jurema da Silva Herbas Palomo, RN, MSc, PhD
OBJECTIVE. The study aims to identify the nursing
diagnoses and interventions for a child requiring
intra-aortic balloon pump support.
METHODS. This was a case study of a 7-year-old child.
The nursing diagnoses and interventions were obtained
by three cardiology and pediatric specialist nurses,
familiar with NANDA-International and Nursing
Intervention Classification taxonomies.
RESULTS. Many nursing diagnoses and interventions
were identified, but the main diagnosis for this patient
was decreased cardiac output.
CONCLUSIONS. The nursing care for a child with an
intra-aortic balloon requires well-qualified professionals,
prepared to handle the diagnoses and interventions
identified in this study.
PRACTICAL IMPLICATIONS. The use of a standard
language system is essential to guide professionals in
the caring process, providing essential elements to
optimize interpretations.
Search terms: Intra-aortic balloon pumping, nursing
care, nursing diagnosis
Resumo
OBJETIVO. Identificar os diagnósticos e as intervenções
de enfermagem de uma criança com balão intra-aórtico.
MÉTODOS. Estudo de caso de uma criança de sete
anos em uso de balão intra-aórtico. A coleta de dados foi
realizada retrospectivamente por meio do prontuário.
Os diagnósticos e intervenções de enfermagem foram
levantados por três enfermeiras especialistas em
cardiologia e pediatria e com domínio nas taxonomias
da NANDA-I e NIC.
© 2011, The Authors
International Journal of Nursing Terminologies and
Classifications © 2011, NANDA International
doi: 10.1111/j.1744-618X.2010.01172.x
International Journal of Nursing Terminologies and Classifications Volume 22, No. 1, January-March, 2011
ijnt_1172 23..32
RESULTADOS. O principal diagnóstico de enfermagem
encontrado para este paciente foi o débito cardíaco
diminuído relacionado à contratilidade alterada. Outros
diagnósticos de enfermagem encontrados foram: risco de
infecção, risco de aspiração, constipação, integridade da
pele prejudicada, nutrição desequilibrada: menos do que
as necessidades corporais, risco de perfusão renal
ineficaz, proteção ineficaz, risco de sangramento e
volume de líquidos excessivo. Para cada diagnóstico de
enfermagem foram encontradas muitas intervenções e
atividades.
CONCLUSÕES. A assistência de enfermagem a uma
criança portadora de balão intra-aórtico exige
experiência, profissionais qualificados e preparados para
lidar com os diagnósticos e intervenções identificados
neste estudo.
IMPLICAÇÕES PARA PRÁTICA. A utilização de um
sistema padronizado de linguagem é
fundamental para guiar os profissionais
no processo de cuidar, possibilitando a
organização dos nossos pensamentos,
observações e interpretações. Para assegurarmos a
efetividade das intervenções apresentadas, sugerimos a
realização de novos estudos, visando a aplicação e
avaliação destas atividades de enfermagem.
Descritores de Assunto. Diagnóstico de Enfermagem,
Cuidados de Enfermagem, Estudos de Caso, Balão
Intra-Aórtico, Criança.
Juliana de Lima Lopes, RN, MSc, Silmara Meneguim,
RN, MSc, PhD, Claudia Cristina Soares Muniz, RN,
MSc, PhD, and Jurema da Silva Herbas Palomo, RN,
MSc, PhD, are nurses in the Nursing Department, Heart
Institute (InCor), Medical School, University of São
Paulo, São Paulo, Brazil.
23
Nursing Diagnoses and Interventions for a Child with Dilated Cardiomyopathy Requiring
Intra-aortic Balloon Pump Support—Case Report
Introduction
Cardiac diseases can be commonly identified in chil-
dren, and dilated cardiomyopathy is one of them. The
annual incidence is two to eight cases per 100,000 in the
United States and Europe, with a prevalence estimated
to be 36 individuals in 100,000 if all age groups are
included (Carvalho, 2002).
Frequently, these children progress to cardiogenic
shock and one of the treatments is the intra-aortic
balloon. However, even though this treatment is widely
used in adult patients, its use is still limited in pediatric
patients.
Given this context, it is extremely important to iden-
tify nursing diagnoses and nursing interventions to
these patients in order to improve the care provided.
Several studies have confirmed the benefits of the
use of classification systems, among them the stan-
dardization language and systematization of care pro-
vided (Assis, Barros, & Zanatta, 2007; Lopes, Barros, &
Michel, 2009; Vargas & França, 2007).
Currently, there are several classifications of nursing
diagnoses and interventions. However, the most used
are the NANDA-International and Nursing Interven-
tions Classification (NIC), respectively.
These classification systems appear to be the most
global and well-developed systems, which when
used in combination, can indicate the most com-
plete nursing care data (Von Krogh, Dale, & Nåden,
2005). When these are used to structure nursing
information systems in hospitals and other health-
care organizations, it will be possible to make
nursing care and its associated activities and achieve-
ment of nursing-sensitive outcomes evident (Lunney,
2006).
Background
The most frequent causes of the development of
dilated cardiomyopathy in children younger than 2
years old are myocarditis and endocardial and idio-
24 International Journal of Nursing Terminologies and Classifications Volume 22, No. 1, January-March, 2011
pathic fibroelastosis (Matitiau et al., 1994). As to
disease progression, children can experience total reso-
lution and condition improvement; however, some
may experience residual dysfunction, cardiogenic
shock, and death (Wiles et al., 1991).
Cardiogenic shock, resulting from myocardial dys-
function, is one of the most severe evolutions of dilated
cardiomyopathy, and its treatment is based on vasoac-
tive drugs. It is a disturbing event, requiring mechani-
cal ventilation and dialysis (Jatene et al., 2008). In some
situations, such measures are not sufficient to contain
the fatal outcome (Hsu et al., 2003). Sometimes,
mechanical circulatory assistance with an intra-aortic
balloon pump can be indicated to improve the clinical
condition of the patient (Jucá, Moreira, Carmona, Stolf,
& Jatene, 1998) and it can be used as a bridge to trans-
plantation (Cochran, Starkey, Panos, & Kunzelman,
2002; Minich et al., 2001).
The counterpulsation provided by the intra-aortic
balloon pump has hemodynamic effects that are
beneficial to cardiac output, in addition to a signifi-
cant decrease in cardiac workload. These effects result
from a decrease in the postload and left ventricular
diastolic end pressure, thus increasing coronary
perfusion by an increase in the aortic diastolic
pressure, which results in improvement in cardiac
output and decreasing myocardial oxygen con-
sumption (Geiger et al., 1997; Rodrigues, Marques, &
Gonçalves, 2007).
The use of an intra-aortic balloon pump has satisfac-
tory results in adults, including in relation to nursing
diagnoses and interventions (Alves, Rocha, & Ferreira,
1999; Jatene et al., 2008; Reid & Cottrell, 2005; Umeba-
yashi & Kawamoto, 1978). However, given the com-
plexity required for the care of children, few medical
centers have the special facilities for appropriate treat-
ment. The difficulties encountered in carrying out this
procedure in children are mainly because of insertion
and maintenance. It is difficult to insert the balloon
through small arteries, because there is a high risk for
arterial injury. Another reason is the difficulty of
synchronizing the balloon phases of inflation and
deflation with the children’s rapid cardiac cycle, even
when arrhythmias are absent (Fuchs & Netz, 2002;
Ibrahim, Duncan, Blume, & Jonas, 2000).
Studies about the use of the intra-aortic balloon
pump in children describe the experience of the
centers before the procedure and the importance of
nursing expertise and extensive knowledge in the field
of cardiology (Cochran et al., 2002; Geiger et al., 1997),
and other studies describe the application of nursing
care to these children (Anella, McCloskey, & Vieweg,
1990).
Because it is rarely used in children and considering
that we faced a child in need of mechanical circulatory
assistance through an intra-aortic balloon pump,
we had to establish a scientific rationale for nursing
actions to direct the care of this child.
Purpose
The purpose of this study was to identify the
nursing diagnoses and interventions for a child using
an intra-aortic balloon pump.
Case Description
F.A.F.J. is a 7-year-old white male who has been
followed at the study healthcare institution since
2004, with a diagnosis of dilated cardiomyopathy and
heart failure. In August 2005, the condition evolved
with worsening of fatigue associated with vomiting
and palpitations. The child was then admitted for
assessment for heart transplantation. After admission,
the condition worsened, and intubation, mechanical
ventilation support, and peritoneal dialysis were nec-
essary. On September 21, 2005, the patient’s hemody-
namic levels decreased, and instillation of an intra-
aortic balloon pump was needed. During the physical
examination, 1 day after the intra-aortic balloon instil-
lation, the patient was under sedation. The Ramsay
Scale was used to assess the level of sedation of the
child. The value found in the clinical evaluation was 6,
indicating a lack of response to stimuli; the patient
International Journal of Nursing Terminologies and Classifications Volume 22, No. 1, January-March, 2011
was pinkish, acyanotic and anicteric, eupneic, and
was intubated under mechanical ventilation. The
mode and parameters were pressure support with
synchronized intermittent mandatory ventilation,
positive end-expiratory pressure = 10 cm H2O, frac-
tion of inspired oxygen = 30%, respiratory rate =
20/20 bpm, good lung expansion, presence of vesicu-
lar murmur and crackles, and 93–99% oxygen satura-
tion. Hemodynamically, the patient was unstable and
dependent on vasoactive drugs, and had a hyperdy-
namic precordium, rhythmic and normophonetic
heart sound, the presence of S3 sounds, systolic and
diastolic murmur in the mitral focus, good pulse
range, and using an intra-aortic balloon pump. Other
findings were a distended abdomen, absent bowel
sounds, stool elimination absent for 11 days, liver at
3 cm of the intercostal edge, the child was fasting,
keeping tube feeding open. Oliguric (6 mL/hr diure-
sis) and intake–output record was +102 mL (fluid
intake = 1,317 mL and output = 1,215 mL); urinary
elimination was through an indwelling vesical cath-
eter; and the peritoneal dialysis procedure was con-
ducted through a Tenchkoff catheter. Generalized
edema was present as was a grade II pressure ulcer,
with granulation tissue in the occipital area. The
medications administered during hospitalization
were milrinone, dobutamine, sedatives, continuous
furosemide, and heparin administered through a
double-lumen catheter.
Vital Signs
Temperature = 36–37.2°C (96.8–99°F); heart rate =
118–144 (bpm).
Mean arterial pressure = 50–95 mm Hg; central
venous pressure (CVP) = 20–22 mm Hg, oxygen satu-
ration = 93–99%, respiratory rate = 20 bpm.
Laboratory Tests
Potassium = 3.7 mEq/L; urea = 142 mg/dL; creati-
nine = 3.1 mg/dL; lactate = 10 mg/dL; albumin =
25
Nursing Diagnoses and Interventions for a Child with Dilated Cardiomyopathy Requiring
Intra-aortic Balloon Pump Support—Case Report
3.0 g/dL; hemoglobin = 11.2% g/dL; hematocrit =
33.0%; total white blood cells = 8.800; platelets
= 138,000/mL; altered clotting; pH = 7.32; PCO2 =
36 mm Hg; PO2 = 126 mm Hg; oxygen saturation =
99%; bicarbonate = 18 mEq/L.
Methods
The case study method was used in this investiga-
tion. This method allowed a better understanding of
the study subject and the identification of the nursing
diagnoses and intervention plan.
Data collection was carried out at the children’s
intensive care unit at a cardiology-specialized public
healthcare institution in São Paulo, Brazil. The unit has
nine beds for patients with congenital or acquired heart
disease cardiopathies.
The study subject was a 7-year-old male admitted
with a medical diagnosis of dilated cardiomyopathy,
in need of an intra-aortic balloon pump. It is worth
noting that data were collected retrospectively
from the medical records 1 day after the intra-
aortic balloon was passed into the patient’s aorta.
NANDA—North American Nursing Diagnosis Asso-
ciation (2007–2008) was used to identify the nursing
diagnoses, and NIC (McCloskey and Bulechek, 2003)
for the intervention survey. The nursing diagnoses
and interventions were surveyed by three specialized
cardiology nurses with clinical experience in pediat-
rics, and all are familiar with the taxonomies.
The patient’s presenting symptoms were identified
(the evidence). Then the nursing diagnoses were deter-
mined based on this evidence. Evidence included units
of data, for example, the patient’s respiratory rate,
which a nurse collected during the evaluation, inten-
tional or nonintentional (Lunney, 2004).
Once the nursing diagnosis was established, the
interventions were identified and nursing activities
relevant to this child were selected.
The approach of the diagnoses and interventions
were based on the physiological aspects of the child,
because this research was a retrospective study and
26 International Journal of Nursing Terminologies and Classifications Volume 22, No. 1, January-March, 2011
information related to psychological, social, and family
factors were not described in the medical records.
Findings
Clinical judgment and critical thinking were
required in the survey of the child’s problems and
were interrelated with the defining characteristics or
the risk factors found in NANDA-International. After
this survey, the nursing diagnoses were identified, as
shown in Table 1.
After identification of the nursing diagnoses, the
nursing interventions and the proposed activities were
planned to be implemented in clinical practice, accord-
ing to NIC taxonomy (Table 2).
Discussion
Children in need of an intra-aortic balloon pump
require highly specialized care. In this case study,
several nursing diagnoses were identified, such as in
the study of Anella et al. (1990), which identified the
potential for decreased cardiac output, alterations in
respiratory function, potential for alteration in renal
vascular circulation, potential for alteration in gas-
trointestinal vascular circulation, potential for infection,
alteration in protection, and potential for bleeding.
One diagnosis in particular can be considered the
priority for this patient: decreased cardiac output
related to altered contractility. The other nursing diag-
noses possibly resulted from the decreased cardiac
output because of pathophysiological changes intrinsic
to dilated cardiomyopathy.
This disease is characterized by ventricular dilation,
systolic contractible dysfunction, low cardiac output
and therefore congestive heart failure symptoms, such
as crackles and edema that lead to the nursing diagno-
sis of excess fluid volume. With decreased cardiac
output, there is a decrease in blood supply and oxygen
supply, resulting in renal and gastrointestinal hypop-
erfusion, which can lead to kidney failure, abdominal
fullness, and constipation, thus justifying the following
Table 1. Identification of Problems, Defining Characteristics, or Risk Factors and Nursing Diagnoses
Identified in a Child in Use of an Intra-aortic Balloon Pump
Defining Related factors Nursing
Identification of problem characteristics or risk factors diagnoses

• Intubation — • Invasive procedures Risk for infection

• Tenckoff catheter
• Double-lumen catheter
• Intra-aortic balloon
• Indwelling vesical catheter
• Distended abdomen, absent — • Tube feedings Risk for aspiration
bowel sounds • Reduced level of
• Sedation (Ramsay = 6) consciousness
• Intubation • Presence of
• Tube feeding endotracheal tube
• Decreased
gastrointestinal motility
• Dilated cardiomyopathy • Generalized edema • Altered contractility Decreased cardiac
• Intra-aortic balloon • Crackles output
• Crackles • Increased central
• Dependent on vasoactive drugs venous pressure
• Presence of S3 sounds • Oliguria
• Edema • Variations in blood
• Oliguria pressure readings
• Central venous • S3 sounds
pressure = 20 a 22
• Mean arterial
pressure = 50 to 95 mm Hg
• Stool elimination absent for 11 days • Change in bowel pattern • Change in eating patterns Constipation
• Absent bowel sounds • Decreased frequency • Decreased motility
• Hypoactive bowel sounds of gastrointestinal tract
• Keeping the feeding tube open Reported food intake less than • Biological factors Imbalanced nutrition:
• Child was fasting recommended daily allowance less than body
requirements
• Presence of grade II pressure ulcer • Destruction of skin layers • Imbalanced nutritional state Impaired skin
• Physical immobilization integrity
• Impaired circulation
• Peritoneal dialysis — • Treatment-related side effects Risk for Ineffective
• Mean arterial • Metabolic acidosis Renal Perfusion
pressure = 50 mm Hg
• Oliguria (6 mL/hr)
• Urea = 142
• Creatinine = 3,1
• Ph = 7.32, Bic = 18
• Presence of grade II pressure ulcer • Altered clotting • Abnormal blood profiles Ineffective protection
• Altered clotting • Pressure ulcers • Inadequate nutrition
• Altered clotting — • Treatment-related side effects Risk for bleeding
• Intra-aortic balloon • Inherent coagulopathies
• Anticoagulated
• Crackles • Edema • Compromised regulatory Excess fluid volume
• Presence of S3 sounds • S3 heart sound mechanism
• Edema • Oliguria
• Central venous pressure = 20–22 • Pulmonary congestion
• Intake record = 1,317 mL • Intake exceeds output
• Output record = 1,215 mL

International Journal of Nursing Terminologies and Classifications Volume 22, No. 1, January-March, 2011 27
Nursing Diagnoses and Interventions for a Child with Dilated Cardiomyopathy Requiring
Intra-aortic Balloon Pump Support—Case Report
Table 2. Nursing Activities, Proposed by NIC, according to the Diagnoses and Interventions
Identified in a Child in Use of an Intra-aortic Balloon Pump
Nursing diagnosis Nursing interventions
Risk for • Infection protection
infection • Airway management
Risk for • Aspiration precautions
aspiration • Enteral tube feeding
Decreased • Shock management
cardiac output • Shock management:
cardiac
• Circulatory care:
mechanical assist devices
28 International Journal of Nursing Terminologies and Classifications Volume 22, No. 1, January-March, 2011
Activities
• Monitor for systemic and localized signs and symptoms of infection.
• Monitor absolute granulocyte count, WBC, and differential results.
• Obtain cultures, as needed.
• Ensure aseptic handling of all IV lines.
• Promote sufficient nutritional intake.
• Report suspected infections to infection control personnel.
• Auscultate breath sounds, noting areas of decreased or absent ventilation and
presence of adventitious sounds.
• Perform endotracheal suction, as appropriate.
• Note type and amount of secretions obtained.
• Position upright 90 degrees or as far as possible.
• Keep tracheal cuff inflated.
• Keep suction setup available.
• Check NG placement before feeding.
• Check NG residual before feeding.
• Discontinue feedings 30–60 min before putting in a head-down position.
• Irrigate the tube every 4–6 hr during continuous feedings and before each intermittent
feeding.
• Check gravity drip rate or pump rate every hour.
• Hold tube feedings if residual is grater than 150 cc or more than
110–120% of the hourly rate in adults.
• Auscultate lung sounds for crackles or other adventitious sounds.
• Note signs and symptoms of decreased output.
• Monitor trends in blood pressure and hemodynamic parameters, if available (e.g.,
central venous pressure and pulmonary capillary/artery wedge pressure).
• Monitor fluid status, including intake and output, as appropriate.
• Administer vasoactive medications.
• Monitor determinants of tissue oxygen delivery (e.g., PaO2, SaO2, and
hemoglobin levels and cardiac output), if available.
• Monitor symptoms of inadequate tissue oxygenation (e.g., pallor, cyanosis,
and sluggish capillary refill).
• Note tachycardia, decreased blood pressure, or abnormally low systemic
arterial pressure, as well as pallor, decreased capillary refill, and diaphoresis.
• Monitor renal function (e.g., BUN and Cr levels), if appropriate.
• Monitor peripheral perfusion.
• Monitor gastrointestinal functioning (e.g., distension and bowel sounds).
• Draw arterial blood gases and monitor tissue oxygenation.
• Monitor lab values for changes in oxygenation or acid-base balance, as appropriate.
• Offer emotional support to the family.
• Perform a comprehensive appraisal of peripheral circulation (e.g., check
peripheral pulses, edemas, capillary refill, color, and extreme temperature).
• Observe cannulas for kinks or disconnection.
• Monitor the device regularly to ensure proper functioning.
• Monitor coagulation profiles every 6 hr, as appropriate.
• Administer anticoagulants or antithrombolytics, as ordered.
• Obtain chest X-ray daily.
• Use strict aseptic technique in changing dressings.
• Administer pain medications, as needed.
• Teach family about the device.
Table 2. Continued
Nursing diagnosis Nursing interventions Activities

Constipation • Constipation/ • Monitor signs and symptoms of constipation.

Impaction management • Monitor bowel movements, including frequency, consistency, shape, volume, and
color, as appropriate.
• Monitor bowel sounds.
• Consult physician if signs and symptoms of constipation or impaction persist.
• Identify factors (e.g., medications, bed rest, and diet) that may cause or contribute to
constipation.
• Consult with physician about a decrease/increase in frequency of bowel sounds.
• Administer laxative or irrigation, as appropriate.
• Remove the fecal impaction manually, if necessary.
Imbalanced • Nutrition therapy • Monitor food/ fluid ingested and calculate daily caloric intake, as appropriate.
nutrition: • Diet staging • Ensure that diet includes foods high in fiber content to prevent constipation.
less than body • Determine presence of bowel sounds.
requirements • Institute NPO, as needed.
• Clamp nasogastric tube and monitor tolerance, as appropriate.
• Monitor for alertness and presence of gag reflex, as appropriate.
• Collaborate with other healthcare team members to progress diet as rapidly as
possible without complications.
• Monitor tolerance to diet progression.
Impaired skin • Pressure ulcer care • Describe characteristics of the ulcer at regular intervals, including size (L ¥ W ¥ D),
integrity stage (I–IV), location, exudate, granulation or necrotic tissue, and epithelization.
• Monitor color, temperature, edema, moisture, and appearance of surrounding skin.
• Keep the ulcer moist to aid in healing.
• Debride ulcer, as needed.
• Cleanse the ulcer with the appropriate solution.
• Apply saline soaks, as appropriate.
• Apply a permeable adhesive membrane to the ulcer, as appropriate
• Monitor for signs and symptoms of infection in the wound.
• Position every 1–2 hr to avoid prolonged pressure.
• Utilize specialty beds and mattresses, as appropriate.
• Ensure adequate dietary intake.
• Monitor nutritional status.
Risk for ineffective • Fluid/electrolyte • Monitor for abnormal serum electrolyte levels, as available.
renal perfusion management • Set an appropriate intravenous infusion flow rate.
• Peritoneal dialysis • Monitor hemodynamic status, including CVP, MAP, PAP, and PCWP levels, if
therapy available.
• Monitor vital signs, as appropriate.
• Consult physician if signs and symptoms of fluid and/or electrolyte imbalance
persist or worsen.
• Prepare patient for dialysis, as appropriate.
• Warm the dialysis fluid before instillation.
• Assess patency of catheter, noting difficulty in inflow/outflow.
• Maintain record of inflow/outflow volumes and individual/cumulative fluid balance.
• Monitor blood pressure, pulse, respirations, temperature, and patient response during
dialysis.
• Ensure aseptic handling of peritoneal catheter and connections.
• Draw laboratory samples and review blood chemistries (e.g., blood urea nitrogen,
serum creatinine, and serum NA, K, and PO4 levels).
• Obtain cell count cultures of peritoneal effluent, if indicated.
• Measure and record abdominal girth.
• Check equipment and solutions, according to protocol.
• Administer dialysis exchanges (inflow, dwell, and outflow), according to protocol.
• Monitor signs of infection (e.g., peritonitis and exit site inflammation/drainage).
• Monitor for signs of respiratory distress.
• Monitor for bowel perforation or fluid leaks.

International Journal of Nursing Terminologies and Classifications Volume 22, No. 1, January-March, 2011 29
Nursing Diagnoses and Interventions for a Child with Dilated Cardiomyopathy Requiring
Intra-aortic Balloon Pump Support—Case Report

Table 2. Continued
Nursing diagnosis Nursing interventions Activities

Risk for bleeding • Bleeding precautions • Monitor the patient closely for hemorrhage.
• Monitor coagulation studies, including prothrombin time (PT), partial thromboplastin
time (PTT), fibrinogen, fibrin degradation/split products, and platelets counts, as
appropriate.
• Administer blood products (e.g., platelets and fresh frozen plasma), as appropriate.
• Use soft toothbrush or toothettes for oral care.
• Avoid invasive procedure; if they are necessary, monitor closely for bleeding.
Ineffective • Bleeding precautions • Monitor the patient closely for hemorrhage.
protection • Monitor coagulation studies, including PT, PTT, fibrinogen, fibrin degradation/split
products, and platelet counts, as appropriate.
• Avoid constipation.
• Administer blood products (e.g., platelets and fresh frozen plasma), as appropriate.
• Use soft toothbrush or toothettes for oral care.
• Avoid invasive procedure; if they are necessary, monitor closely for bleeding.
Excess fluid • Fluid management • Count or weigh diapers, as appropriate.
volume • Electrolyte management • Maintain accurate intake and output record.
• Hypervolemia • Monitor laboratory results relevant to fluid retention (e.g., increased specific gravity,
management increased BUN, decreased hematocrit, and increased urine osmolality levels).
• Monitor hemodynamic status, including CVP, MAP, PAP, and PCWP, if available.
• Monitor vital signs, as appropriate.
• Monitor for indications of fluid overload/retention (e.g., crackles, elevated CVP or
pulmonary capillary wedge pressure, edema, neck vein distention, and ascites), as
appropriate.
• Assess location and extent of edema, if present.
• Monitor nutrition status.
• Administer prescribed diuretics, as appropriate.
• Monitor for therapeutic effect of diuretic (e.g., increased urine output, decreased
CVP/PCWP, and decreased adventitious breath sounds).
• Consult physician if signs and symptoms of fluid and/or electrolytes imbalance
persist or worsen.
• Monitor potassium levels.
• Monitor for manifestations of electrolyte therapy.

BUN, blood urea nitrogen; Cr, creatinine; CVP, central venous pressure; IV, intravenous; MAP, mean arterial pressure; NIC, Nursing
Interventions Classification; NG, nasogastric tube; NPO, nil per os; PAP, positive airway pressure; PCWP, pulmonary capillary wedge
pressure; WBC, white blood cell.

diagnoses: risk for ineffective renal perfusion; poor
nutritional habits, i.e., eating less than the body
requires; risk of aspiration; and constipation.
One possible treatment for decreased cardiac output
involves vasoactive drugs; however, this treatment
may not be enough to maintain the individual’s
primary functions, resulting in the need for mechanical
circulatory support, such as the intra-aortic balloon
pump (Osterne et al., 1999). Because it is an invasive
procedure, infections may occur (risk for infection),
and platelet activation resulting in thrombus formation
may also occur. That is why the patient needs, most of
the time, to be simultaneously anticoagulated, thus
providing for changes in blood-clotting cascade (inef-
fective protection and risk for bleeding). Another basic
requirement is total rest, which can trigger pressure
areas and the appearance of pressure ulcers (impaired
skin integrity).
Therefore, nursing interventions must be priori-
tized. In addition, it is worth pointing out that
nursing care implementation must be carried out by
following a protocol aimed at all the nursing diag-
noses surveyed by the nurse. Actually, few studies
describe the nursing interventions required for a

30 International Journal of Nursing Terminologies and Classifications Volume 22, No. 1, January-March, 2011
child using an intra-aortic balloon pump. The study
by Geiger et al. (1997) reports that the assessment
includes recording intra-aortic balloon parameters,
vital signs (especially pulse and perfusion of the
extremity distal to the balloon catheter), urine output,
and laboratory results essential to the patient’s care.
They also report that a specific, specialized approach
is an effective way to care for these ill patients. Anella
et al. (1990) report that the interventions should be
based on the monitoring of cardiovascular parameters
(heart rate, rhythm, blood pressure, CVP); peripheral
perfusion (quality of all peripheral pulses, tempera-
ture, color, and capillary refill); maintenance of
adequate ventilation and oxygenation (monitor respi-
ratory rates and quality of breath sounds, monitor
arterial blood gases, and daily chest X-rays); mainte-
nance of adequate urine output and renal function,
including monitoring of BUN and creatinine daily;
assessment of bowel sounds; prevention of infection,
including the use of strict aseptic technique, protec-
tion of catheter site from perineal contamination,
monitoring for signs of local infection at insertion site
and the temperature; and monitoring for potential
bleeding.
These studies and the present research suggest the
same activities and interventions for a child in use of an
intra-aortic balloon pump. With the use of classifica-
tions of nursing diagnoses and interventions, the
nurses will have several advantages, including the stan-
dardization of language and the organization and sys-
tematization of the activities, thus providing a
scientifically necessary approach for professional activi-
ties and implementations.
Conclusion and Implications for Practice
The nursing care of a child with an intra-aortic
balloon requires not only an experienced and highly
qualified nurse, but also a professional able to make
rational and objective decisions when facing the differ-
ent diagnoses and interventions as identified in this
study.
International Journal of Nursing Terminologies and Classifications Volume 22, No. 1, January-March, 2011
The use of a standard language system is essential
to guide nurses along with the caring process, provid-
ing essential elements to optimize interpretations. To
assure the efficacy of the interventions discussed, we
suggest new studies aiming at the application and
evaluation of nursing activities and other studies
aiming at the approach of the diagnoses and interven-
tions based on all aspects such as physiologically and
psychologically for a holist care.
Author contact: julianalimalopes@gmail.com
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