Nursing Diagnosis: Decreased cardiac output due to decreased vascular volume secondary to third spacing as evidenced by pitting edema

of +4, blood pressure of 84/50, and urine output of 200ml/8 hours. Goal: Patient will regain and maintain adequate cardiac output.

Intervention:
1. Assess pulse oximetry every 4h and prn

Rationale:
1. A pulse oximetry reading determines the amount of hemoglobin in the blood that is saturated with oxygen. Fluid shift from vascular space decreases circulating blood volume thereby decreasing cardiac output. Decreased cardiac output is directly correlated to decreased oxygenation (NDH 201).

Outcome Criteria:
1. Pt's pulse oximetry will be >93% as assessed q4hrs

Evaluation:
1. Unmet. Pt's pulse oximetry was 92% and required 5 liters of oxygen to maintain that level.

2. Assess heart rate every 4 hrs and prn

2. Heart rate is directly proportional to cardiac output. 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. Decreased cardiac output increases SNS stimulation and increases the heart rate. (Lewis 1686)

2. Pt's heart rate will be assessed every 4 hrs and be in the range of 60 to 100 bpm.

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

3. Assess blood pressure every 4 hrs and prn

3. Blood pressure is the pressure exerted by circulating blood upon the walls of blood vessels. 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)

3. Pt's blood pressure will trend towards 120/80 as assessed every 4hrs by end of clinical weekend.

3. Unmet. Pt's blood pressure fell as low as 84/50.

4. Assess lung sounds every 4hrs 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 prior to hospital discharge.

4. Unmet. Patients lung sounds remained adventitious.

5. Assess skin color and temperature every 4 hrs and prn

5. Cool clammy skin is secondary to compensatory 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 and pink skin indicates blood flow is reaching the tissues and perfusing them with oxygen. (Lewis 778)

5. Pt's skin will remain pink and warm as assessed every 4 hrs and prn.

5. Unmet. Patients skin color remained pink but temperature was cool.

6. Monitor daily weight

6. Accurate daily weights provide the easiest measurement 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)

6. Patient weight will remain stable and not increase by more than 2 lbs in 48 hrs.

6. Unmet. Patient weight increased by 3 lbs in 48 hrs.

7. Monitor LOC every 4 hrs and prn

7. Decreased blood pressure and volume does 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. Patient will be alert and oriented X 3 when assessed every 4 hrs.

7. Unmet. Patient had periods of disorientation.

8. Monitor intake and output every shift

8. Decreased cardiac output results in decreased perfusion to the kidneys and decreased urine output. Urinary output should be >30 ml/hr (Lewis 1012).

8. Urinary output will be >30ml/hour every shift.

8. Unmet. Patients urinary output 200ml per 8 hr shift.

9. Monitor for signs and symptoms of heart failure every 4 hrs.

9. Symptoms of heart failure include include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue, crackles in the lungs, and edema. When cardiac output is insufficient, heart failure can occur (NDH 198).

9. Patient will be free of s/s heart failure prior to hospital discharge.

9. Unmet. Patient had pitting edema and crackles in lower lung fields.

10. Provide rest periods every shift

10. Rest helps lower arterial pressure and reduce the workload of the myocardium by diminishing the requirements for cardiac output. Activities such as eating a meal can increase the workload of the heart. Periods of rest are important to prevent a decrease in cardiac output (NDH 200).

10. Periods of rest will be provided every shift.

10. Met. Patient was given frequent rest periods during care and meals.

11. Palpate peripheral pulses every shift.

11. Decreased cardiac output may be reflected in diminished radial, popiliteal, dorsalis pedis, and post tibial pulses. Pulses may be irregular or fleeting to palpation. (NDH 200)

11. Patient will have regular palpable pulses every shift.

11. Met. Patients peripheral pulses palpated every shift.

12. Elevate extremities when out of bed.

12. Elevating extremities promotes venous return and decreases venous pooling/stasis. (Lewis 1083)

12. Patient will have decreased edema within 24 hrs.

12. Unmet. Patient had +4 pitting edema of lower extremities.

13. Administer Lasix 20mg IVP every 12 hrs.

13. Lasix inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule, increasing renal excretion of water and sodium. This results in the mobilization of excess fluid and decreases blood pressure (Davis p. 620).

13. Lasix will be administered every 12 hrs per order.

13. Met. Lasix was administered as ordered and resulted in increased urinary output.

14. Administer Digoxin 125mcg po once daily

14. Digoxin causes increased cardiac output and slowing of the heart rate and increases the force of myocardial contraction. (Davis p. 431).

14. Digoxin will be administered once daily and patient heart rate will be regular rate and rhythm.

14. Met. Patient received Digoxin 125mcg po daily and heart rate remained in normal limits.