Kapiolani Community College

LPN-RN Transition Program

NURS220 Nursing Care Plan
Student Name: Jane Stubbert
Date of Care: 06/30/2016
Nursing Diagnosis: Decreased cardiac output

Date Submitted: 11/12/13

Related to: chronic heart failure secondary to rheumatic heart disease

As manifested by: heart murmurs, decreased activity intolerance or fatigue, decreased urinary output, dyspnea, and crackles.
Scientific Rationale: Heart failure is described as a common clinical syndrome resulting in the inability of the heart to meet the hemodynamic and
metabolic demands of the body. The goal of treating heart failure is to control symptoms, assist in managing the disease, and improve quality of
life.
Reference (APA format): Gulanick, M., and Myers, J. (2011). Nursing care plans: Diagnoses, interventions,
and outcomes. (7th ed) St. Louis, MI: Elsevier.

Measurable
Outcomes:
Short Term Outcome:
1.
Patient will be
free from crackles in
lungs by adequately
coughing up
secretions during
the shift.
2.
Patient will get
out of bed at least
3x as tolerated
during the shift.
Long Term Outcome:
1. After surgery,
patient maintains
adequate cardiac
output as evidence by
strong peripheral
pulses, BP within
normal range for age,
urinary output >30
ml/hr, warm and dry
skin, eupnea with
absence of pulmonary
crackles by discharge.

Interventions:

Rationale (w/ references):

Evaluation:

1.

1.

1.

Assess heart
sounds, VS, peripheral
pulses, capillary refill.
2.
Assess breath
sounds.
3.
Assess weight, skin
color and temperature,
urinary output.
4.
Monitor serum
electrolytes and digitalis
level.
5.
Administer
ampicillin-subactam,
captopril, chlorothiazide,
digoxin, furosemide, and
spironolactone.
6.
Encourage low salt
intake. Ask patient what
she likes to eat that can
be ordered special for
her.
7.
Mitral valve surgery
scheduled for 11/12/13.
8.
Start patient on
ferrous sulfate as
prescribed. Hgb 10.5
g/dL and Hct 33.6%.
9.
Assist patient with
ambulation in slow
progression as tolerated.
10.
Continue droplet
precautions for
pneumonia as ordered.

Murmurs and/or
second heart sounds
may be auscultated.
Peripheral pulses and
capillary refills may be
weak with reduced
stroke volume and
cardiac output.
2.
Crackles reflect
accumulation of fluid in
pulmonary circulation.
3.
Weight is an
indication of fluid
retention. Cool, pale,
clammy skin is
secondary to
compensatory increase
in SNS stimulation, low
cardiac output, and
desaturation.
4.
Hyponatremia and
hypochloride are
causative factors for
diuretic use. The margin
for therapeutic and toxic
doses of digitalis is
narrow.
5.
Ampicillin for
pneumonia. Captopril
for reducing BP and
decreasing workload of
heart. Chlorothiazide
and furosemide to
reduce circulating
volume, enhance
sodium and water
excretion, and improve
symptoms. Digoxin to
improve myocardial
contractility.
Spironolactone as a
potassium sparing

Murmurs auscultated, VS
WNL, strong peripheral
pulses, capillary refill <3 sec.
2.
Crackles noted, but clear
after coughing. Patient able
to cough up secretions
adequately. Pulmonary
congestion due to
pneumonia, not heart failure.
Pulmonary crackles not
auscultated in bases of lungs.
3.
No weight gain, skin
warm and dry. Urinary output
25ml/hr.
4.
Sodium 130 and Cloride
95 on 11/8. Could be due to
diuretic use or low salt
intake.
5.
Patient responding well
to medication with no
incidence. Patient likes to
drink water with medication.
6.
Patient compliant with
low salt diet. Patient likes to
eat fruits. Does not like
oatmeal.
7.
Patient is waiting
surgery.
8.
Patient tolerated
medication well with no
incidence. Need to monitor
H&H. Patient likes to drink
water with medication.
9.
Patient has steady gait
and able to ambulate by self
in the room. Patient got up
4x during the shift. Patient
likes to eat sitting next to her
mom.
10. Droplet precautions
discontinued per physician.
Patient has been on