Decreased Cardiac Output - Nursing Care Plan for Heart Failure

Nursing Care Plan for Heart Failure

Nursing Diagnosis : Decreased cardiac output related to the physiological response of the heart muscle, increase in frequency, dilatation, hypertrophy, or an increase in stroke volume.

NOC:
  • Cardiac Pump effectiveness
  • Circulation Status
  • Vital Sign Status
Expected outcomes:
  • Vital Signs in the normal range (blood pressure, pulse, respiration).
  • Can tolerate the activity, there is no fatigue.
  • There are no pulmonary edema, peripheral, and no ascites.
  • There is no loss of consciousness.


NIC:

Cardiac Care
  • Evaluation of chest pain (intensity, location, duration).
  • Note the presence of cardiac dysrhythmias.
  • Note the presence of signs and symptoms of cardiac putput decline.
  • Monitor cardiovascular status.
  • Monitor respiratory status that indicates heart failure.
  • Monitor the abdomen as an indicator of decreased perfusion.
  • Monitor fluid balance.
  • Monitor any changes in blood pressure.
  • Monitor the patient's response to the effects of antiarrhythmic treatment.
  • Set the period of exercise and rest to avoid fatigue.
  • Monitor the patient's exercise tolerance.
  • Monitor the presence of dyspnea, fatigue, tekipneu and ortopneu.
  • Suggest to reduce stress.

Vital Sign Monitoring
  • Monitor BP, pulse, temperature, and respiration.
  • Note the presence of fluctuations in blood pressure.
  • Monitor vital signs while the patient is lying down, sitting, or standing.
  • Auscultation BP in both arms and compare.
  • Monitor BP, pulse, respiration, before, during, and after activity.
  • Monitor the quality of the pulse.
  • Monitor the presence of pulsus paradoxus.
  • Monitor the presence of pulsus alterans.
  • Monitor the amount and heart rhythm.
  • Monitor heart sounds.
  • Monitor the frequency and rhythm of breathing.
  • Monitor lung sounds.
  • Monitor abnormal breathing pattern.
  • Monitor temperature, color, and moisture.
  • Monitor peripheral cyanosis.
  • Monitor the presence of Cushing's triad (widened pulse pressure, bradycardia, increased systolic).
  • Identify the cause of the vital sign changes.

Copyright © 2012 Nursing Diagnosis Nanda. Powered by Blogger.