Nursing Care Plan Patient with Risk for Decreased Cardiac Output

NURSING CARE PLAN Patient’s Initial: ____I____ Age: __73_____ Medical Diagnosis: __Heart Failure_____________________ Gender: __Male_____ Chief Complaint: _Worsening of heart failure_ Assessment Nursing Diagnosis Planning Subjective: - The client have an history of hospitalization due to progressive dyspnea, trigerred by less than ordinary activities, lower-extremity edema and abdominal enlargement. Risk for Decreased Cardiac Output as related to alteration in preload as evidenced by presence of ascites, pedal edema and ECG result revealed cardiomegaly. Short Term Goal: - After 1 day of nursing interventions the client will be able to demonstrates adequate cardiac output as evidenced by : - normal blood pressure - normal urinary output. - After 1 day of nursing interventions the client will be able to report decreased of dyspnea and dysrhythmia as evidenced by: - normal heart rate - normal heart rhythm Objective: - The client is oriented but breaths heavily. - The client has presence of ascites, pedal edema, and paresthesia on hands and feet. - ECG result revealed cardiomegaly and development of pulmonary edema. - Echocardiogram, ECG, paracentesis, blood workups diagnosed progressive heart failure. Long Term Goal: - After 2-3 days of nursing interventions the client will be able to demonstrates an increase in activity tolerance as evidenced by: - decreased occurrence of fatigue - decreased occurrence of dyspnea during and after activities Intervention Date Handled:___Dec. 7, 2020___ Clinical Area: __N/A____________ Rationale Independent: - Position patient in semiFowler’s to high-Fowler’s - to reduce preload and ventricular filling. - Monitor and note the client’s input and output - to monitor cardiac output in perfusion of the kidneys through urine output. - Auscultate heart sounds and note rate, rhythm, presence of S3, S4; and lung sounds. - to monitor onset of a gallop rhythm, tachycardia, and fine crackles in lung bases can indicate heart failure. - Note chest pain. Identify location, radiation, severity, quality, duration - Chest pain is generally suggestive of an inadequate blood supply to the heart, which can compromise cardiac output. Dependent: - Limit fluids and sodium as ordered. - Administer medications as ordered and note the side effects and toxicity. - Administer oxygen therapy as ordered. - Fluid restriction decreases extracellular fluid volume and reduces demands on the heart. - to be able to respond to increased oxygen demands. Oxygen saturation need to be greater than 90%. Evaluation Short Term Evaluation: - After 1 day of nursing interventions the goal to demonstrates adequate cardiac output was: _√ met ___ partially met ___ unmet As evidenced by: - normal blood pressure - normal urinary output. - After 1 day of nursing interventions the goal to report decreased of dyspnea and dysrhythmia was: _√ met ___ partially met ___ unmet As evidenced by: - normal heart rate - normal heart rhythm Long Term Evaluation: - After 2-3 days of nursing interventions the goal to demonstrates an increase in activity tolerance was: _√ met ___ partially met ___ unmet As evidenced by: Interdependent/ Collaborative: - Review laboratory data including the complete blood count, electrolytes, arterial blood gases, function studies of kidney, thyroid and liver. - Review results of EKG and chest Xray. - to identify client at risk and promote early intervention, if indicated. - EKG can reveal previous MI, or evidence of left ventricular hypertrophy. Xray may provide information on pulmonary edema, pleural effusions, or enlarged cardiac silhouette. - decreased occurrence of fatigue - decreased occurrence of dyspnea during and after activities