NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
* Cardiac Pump Effectiveness
* Circulation Status
* Knowledge: Disease Process
* Knowledge: Treatment Program
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
* Cardiac Care
* Hemodynamic Regulation
* Teaching: Disease Process
NANDA Definition: Inadequate blood pumped by the heart to meet the metabolic demands of the body
Common causes of reduced cardiac output include myocardial infarction, hypertension, valvular heart disease, congenital heart disease, cardiomyopathy, pulmonary disease, arrhythmias, drug effects, fluid overload, decreased fluid volume, and electrolyte imbalance. Geriatric patients are especially at risk because the aging process causes reduced compliance of the ventricles, which further reduces contractility and cardiac output. Patients may have acute, temporary problems or experience chronic, debilitating effects of decreased cardiac output. Patients may be managed in an acute, ambulatory care, or home care setting. This care plan focuses on the acute management.
* Defining Characteristics: Variations in hemodynamic parameters (blood pressure [BP], heart rate, central venous pressure [CVP], pulmonary artery pressures, venous oxygen saturation [SVO2], cardiac output)
* Arrhythmias, electrocardiogram (ECG) changes
* Rales, tachypnea, dyspnea, orthopnea, cough, abnormal arterial blood gases (ABGs), frothy sputum
* Weight gain, edema, decreased urine output
* Anxiety, restlessness
* Syncope, dizziness
* Weakness, fatigue
* Abnormal heart sounds
* Decreased peripheral pulses, cold clammy skin
* Confusion, change in mental status
* Ejection fraction less than 40%
* Pulsus alternans
* Related Factors: Increased or decreased ventricular filling (preload)
* Alteration in afterload
* Impaired contractility
* Alteration in heart rate, rhythm, and conduction
* Decreased oxygenation
* Cardiac muscle disease
* Expected Outcomes Patient maintains BP within normal limits; warm, dry skin; regular cardiac rhythm; clear lung sounds; and strong bilateral, equal peripheral pulses.
* Assess mentation. Restlessness is noted in the early stages; severe anxiety and confusion are seen in later stages.
* Assess heart rate and blood pressure. Sinus tachycardia and increased arterial blood pressure are seen in the early stages; BP drops as the condition deteriorates. Elderly patients have reduced response to catecholamines, thus their response to reduced cardiac output may be blunted, with less rise in heart rate. Pulsus alternans (alternating strong-then-weak pulse) is often seen in heart failure patients.
* Assess skin color and temperature. Cold, clammy skin is secondary to compensatory increase in sympathetic nervous system stimulation and low cardiac output and desaturation.
* Assess peripheral pulses. Pulses are weak with reduced cardiac output.
* Assess fluid balance and weight gain. Compromised regulatory mechanisms may result in fluid and sodium retention. Body weight is a more sensitive indicator of fluid or sodium retention than intake and output.
* Assess heart sounds, noting gallops, S3, S4. S3 denotes reduced left ventricular ejection and is a classic sign of left ventricular failure. S4 occurs with reduced compliance of the left ventricle, which impairs diastolic filling.
* Assess lung sounds. Determine any occurrence of paroxysmal nocturnal dyspnea (PND) or orthopnea. Crackles reflect accumulation of fluid secondary to impaired left ventricular emptying. They are more evident in the dependent areas of the lung. Orthopnea is difficulty breathing when supine. PND is difficulty breathing that occurs at night.
* If hemodynamic monitoring is in place:
o Monitor central venous, right arterial pressure [RAP], pulmonary artery pressure (PAP) (systolic, diastolic, and mean), and pulmonary capillary wedge pressure (PCWP). Hemodynamic parameters provide information aiding in differentiation of decreased cardiac output secondary to fluid overload versus fluid deficit.
o Monitor SVO 2 continuously. Change in oxygen saturation of mixed venous blood is one of the earliest indicators of reduced cardiac output.
o Perform cardiac output determination. This provides objective number to guide therapy.
* Monitor continuous ECG as appropriate.
* Monitor ECG for rate; rhythm; ectopy; and change in PR, QRS, and QT intervals. Tachycardia, bradycardia, and ectopic beats can compromise cardiac output. Elderly patients are especially sensitive to the loss of atrial kick in atrial fibrillation.
* Assess response to increased activity. Physical activity increases the demands placed on the heart; fatigue and exertional dyspnea are common problems with low cardiac output states. Close monitoring of patient’s response serves as a guide for optimal progression of activity.
* Assess urine output. Determine how often the patient urinates. Oliguria can reflect decreased renal perfusion. Diuresis is expected with diuretic therapy.
* Assess for chest pain. This indicates an imbalance between oxygen supply and demand.
* Assess contributing factors so appropriate plan of care can be initiated.
* Administer medication as prescribed, noting response and watching for side effects and toxicity. Clarify with physician parameters for withholding medications. Depending on etiological factors, common medications include digitalis therapy, diuretics, vasodilator therapy, antidysrhythmics, ACE inhibitors, and inotropic agents.
* Maintain optimal fluid balance. For patients with decreased preload, administer fluid challenge as prescribed, closely monitoring effects. Administration of fluid increases extracellular fluid volume to raise cardiac output.
* Maintain hemodynamic parameters at prescribed levels. For patients in the acute setting, close monitoring of these parameters guides titration of fluids and medications.
* For patients with increased preload, restrict fluids and sodium as ordered. This decreases extracellular fluid volume.
* Maintain adequate ventilation and perfusion, as in the following:
o Place patient in semi- to high-Fowler’s position. This reduces preload and ventricular filling.
o Place in supine position. This increases venous return, promotes diuresis.
o Administer humidified oxygen as ordered. The failing heart may not be able to respond to increased oxygen demands.
* Maintain physical and emotional rest, as in the following:
o Restrict activity. This reduces oxygen demands.
o Provide quiet, relaxed environment. Emotional stress increases cardiac demands.
o Organize nursing and medical care. This allows rest periods.
o Monitor progressive activity within limits of cardiac function.
* Administer stool softeners as needed. Straining for a bowel movement further impairs cardiac output.
* Monitor sleep patterns; administer sedative. Rest is important for conserving energy.
* If arrhythmia occurs, determine patient response, document, and report if significant or symptomatic.
o Have antiarrhythmic drugs readily available.
o Treat arrhythmias according to medical orders or protocol and evaluate response.
Both tachyarrhythmias and bradyarrhythmias can reduce cardiac output and myocardial tissue perfusion.
* If invasive adjunct therapies are indicated (e.g., intraaortic balloon pump, pacemaker), maintain within prescribed protocol.
Education/Continuity of Care
* Explain symptoms and interventions for decreased cardiac output related to etiological factors.
* Explain drug regimen, purpose, dose, and side effects.
* Explain progressive activity schedule and signs of overexertion.
* Explain diet restrictions (fluid, sodium).