DECREASED CARDIAC OUTPUT
Inadequate blood pumped by the heart to meet the metabolic demands of the body. [Note: In a hypermetabolic state, although cardiac output may be within normal range, it may still be inadequate to meet the needs of the body’s tissues. Cardiac output and tissue perfusion are interrelated, although there are differences. When cardiac output is decreased, tissue perfusion problems will develop; however, tissue perfusion problems can exist without decreased cardiac output.]
· Altered afterload
· Altered contractility
· Altered heart rate
· Altered heart rhythm
· Altered preload
· Altered stroke volume
· Altered Heart Rate/Rhythm: Palpitations
· Altered Preload: Fatigue
· Altered Afterload: Shortness of breath/dyspnea
· Altered Contractility: Orthopnea/paroxysmal nocturnal dyspnea [PND]
· Behavioral/Emotional: Anxiety
· Altered Heart Rate/Rhythm: [Dys]arrhythmias (tachycardia, bradycardia); EKG [ECG] changes
· Altered Preload: Jugular vein distention (JVD); edema; weight gain; increased/decreased central venous pressure (CVP); increased/decreased pulmonary artery wedge pressure (PAWP); murmurs
· Altered Afterload: Cold, clammy skin; skin [and mucous membrane] color changes [cyanosis, pallor]; prolonged capillary refill; decreased peripheral pulses; variations in blood pressure readings; increased/decreased systemic vascular resistance (SVR)/pulmonary vascular resistance (PVR); oliguria; [anuria]
· Altered Contractility: Crackles; cough; cardiac output, 4 L/min; cardiac index, 2.5 L/min; decreased ejection fraction, stroke volume index (SVI), left ventricular stroke work index (LVSWI); S3 or S4 sounds [gallop rhythm] Behavioral/Emotional: Restlessness
The patient will
· Maintain pulse within predetermined limits.
· Maintain blood pressure within predetermined limits.
· Exhibit no arrhythmias.
· Maintain warm and dry skin.
· Exhibit no pedal edema.
· Maintain acceptable cardiac output.
· Verbalize understanding of reportable signs and symptoms.
· Understand diet, medication regimen, and prescribed activity level
Interventions and Rationales:
Monitor patient at least every 4 hr for irregularities in heart rate, rhythm, dyspnea, fatigue, crackles in lungs, jugular venous distension, or chest pain. Any or all of these may indicate impending cardiac failure or other complications. Report changes immediately.
Administer oxygen as ordered to increase supply to myocardium.
Turn and reposition patient at least every 2 hr. Establish a turning schedule for the dependent patient. Post schedule at bedside and monitor frequency. Turning and repositioning prevent skin breakdown and improve lung expansion and prevent atelectasis.
Administer antiarrhythmic drugs, as ordered, to reduce or eliminate rhythm disturbances. Monitor for adverse effects.
Administer stool softeners, as prescribed, to reduce straining during bowel movements.
Measure and record intake and output. Decreased urinary output without decreased fluid intake may indicate decreased renal perfusion resulting from decreased cardiac output.
Weigh patient daily before breakfast to detect fluid retention. Perform active or passive ROM exercises to all extremities every 2–4 hr. ROM exercises foster muscle strength and tone, maintain joint mobility, and prevent contractures.
Inspect legs and feet for pedal edema.
Maintain dietary restrictions, as ordered, to prevent fluid retention, dehydration, weight gain or loss.
Gradually increase levels of activity within prescribed limits of cardiac rate to allow heart to adjust to increased cardiac demands.
Educate patient and his or her family about chest pain and other reportable symptoms, prescribed diet, medications (name, dosage, frequency, and therapeutic and adverse effects), prescribed activity level, simple methods of lifting and bending, and stressreduction techniques. Education promotes remembering of and compliance with techniques to reduce energy consumption.
Provide emotional support and encouragement to help improve patient’s self-concept.
Involve patient in planning and decision making. Having the ability to participate will encourage greater compliance with the plan of treatment.
Have patient perform self-care activities. Begin slowly and increase daily, as tolerated. Performing self-care activities will assist patient to regain independence and enhance self-esteem.
Refer to case manager/social worker to ensure that a home assessment has been done and that whatever modifications are needed to accommodate the patient’s ongoing care have been made. Refer to cardiac program for exercise when the time is appropriate.
Kodiath, K., et al. (2005). Improving quality of life in patients with heart failure: An innovative behavioral intervention. Journal of Cardiovascular Nursing, 20(1), 43–48.