Assessment Subjective: Palaging mababa ang bp nya. As verbalized by his son.

Objectives: Increased heart rate (tachycardia), dysrhythmias, ECG changes Changes in BP (hypotension/hyp ertension) Extra heart sounds (S3, S4) Decreased urine output Diminished peripheral pulses Cool, ashen skin;

Diagnosis Decreased cardiac output related to decreased myocardial contractility

Planning Short Term: After 30 minutes of nursing intervention, the client will be able to: Patients lungs sounds will be clear to auscultation Patient will have no signs of dyspnea Patient will demonstrate an increase in activity intolerance Long Term: After 30 minutes of nursing intervention, the client will be able to: Patient will display hemodynamic stability (BP,

Intervention Assess patient respirations by observing respiratory rate and depth and use of accessory muscles Observe patient for restlessness, agitation, confusion and (late stages) lethargy

Rationale Increased respiratory rate and use of accessory muscles may be seen in patients with hypoxia Changes in behavior and mental status can be early signs of impaired gas exchange which will result from decreased cardiac output Crackles may indicate heart failure which can contribute to decreased cardiac output. Respiratory distress/failure often occurs as shock progresses. A positive hepatojugular reflex is indicative of rightsided heart failure Increasing lethargy, confusion, restlessness and / or irritability can be early signs of cerebral hypoxia from

Evaluation Goal Met. After 3 hours of nursing intervention the client will be able to: Patient has regular, even, non-labored respirations. Patient will be alert, oriented x 3 and calm Patients lungs sounds are clear to auscultation in all lobes Patient has normal hepatojugular reflex. Patient is awake, alert and oriented X3. Patient maintains baseline

Auscultate lungs for presence of normal or adventitious lung sounds

Assess patient for positive hepatojugular reflex

Assess for mental status changes.

diaphoresis Orthopnea, crackles, JVD, liver engorgement, edema Chest pain

cardiac output, urinary output and peripheral pulses WNL)

Weigh patient daily at same time with same clothing on same scale.

Observe patient for sleep apnea

Assess patient for chest pain or discomfort noting location, severity, duration, quality and radiation

Elevate legs when in sitting position and edematous extremities when at rest Monitor hourly urine output

decreased cardiac output Weight gain can be one of the earliest indicators of heart failure as a result of impaired ventricular pumping ability. An acute gain in weight of 1kg. can signal a l liter gain in fluid Sleep apnea is a common disorder in patients with chronic heart failure Chest pain is generally indicative of inadequate blood supply to the heart which can result in decreased cardiac output Improves venous return and increases cardiac output Decreased cardiac output results in decreased perfusion to the kidneys and decreased urine output.

weight or less daily Patient will have no episodes of sleep apnea Patient is free of chest pain. Patient will have decreased edema in legs Patient will have a minimum of 30ml/hr. urinary output Patient has normal heart sounds of S1 and S2 Patient will have normal sinus rhythm Patient will have strong, palpable peripheral pulses in all extremities

Urinary output < 30 ml/hr. indicates inadequate renal perfusion. Assess patient heart sounds Heart sounds may sound distant and have an S3 or S4 sound present with the presence of heart failure Heart irritability is common with conduction defects and/or ischemia from a poorly perfused heart (Tachycardia at rest, atrial fibrillation, bradycardia, or multiple dysrhythmias) Weak, thready peripheral pulses may reflect hypotension, vasoconstriction, shunting and venous congestion Pallor or cyanosis, cool moist skin and slow capillary refill time may be present from peripheral

Monitor patient for changes in heart rate and/or rhythm

Assess peripheral pulses

Observe patient for changes in skin color, moisture, temperature and capillary refill time

Patient will have normal skin color, be dry to touch and have capillary refill time of 3 seconds or less or 5 seconds or less (if patient is elderly) Patients oxygen saturation will remain at 93% or above at all times. Patient will get adequate rest in a stress-free environment. Patient and/or caregiver will verbalize an understandin g of patient medications

Administer supplemental Oxygen as indicated by cannula, mask, or ET/trach tube.

Promote rest

Educate patient and caregivers about the importance of taking prescribed medications at prescribed times

vasoconstriction and decreased oxygen saturation Supplemental oxygen helps to improve cardiac function by increasing available oxygen and reducing oxygen consumption. Rest and a quiet environment reduces a catecholamine-induced stress response and decreases cardiac workload thus increasing cardiac output Patient is often on multiple medications which can be difficult to manage, thus increasing the likelihood that medications can be missed or incorrectly used

and dosing schedule.