Decreased Cardiac Output 734c1w

Melbourne, Florida Individual Nursing Care Plan NURSING DIAGNOSIS STATEMENT Nursing Diagnosis Statement: Risk for decreased cardiac output r/t altered heart rate/rhythm.

GOALS

LONG TERM GOAL: Client will maintain adequate cardiac output AEB BP and pulse within normal range while in hospital 1. SHORT TERM GOAL:

Level of Maslow's Hierarchy: Physiological

INTERVENTIONS

Client will display absence of dysrhythmias

1-1. Palpate radial, carotid, femoral and dorsalis pedis pulses, nothing rate, regularity, amplitude and symmetry. 1-2. Auscultate heart sounds, noting rate, rhythm, presence of extra heartbeats and dropped beats.

1-3. Assess for adequate tissue perfusion and cardiac output, noting any significant variations.

RATIONALE/S

1.1. Differences in equality, rate, and regularity of pulses are indicative of the effect of altered cardiac output on symmetric and peripheral circulation (Doenges, Moorhouse, & Murr, 2014. pp. 92). 1.2. Specific dysrhythmias are more clearly detected audibly than by palpation (Doenges, Moorhouse, & Murr, 2014. pp. 92). 1.3. Although not all dysrhythmias are lifethreatening, immediate treatment may be required to terminate dysrhythmias

IMPLEMENTATION

EVALUATION

(Write nursing progress note that relates to your nursing diagnosis statement and ST goal/s. Palpated radial, carotid, femoral and dorsalis pedis pulses, rate was 65, rhythm was regular, and bilateral pulses symmetrical. Auscultated heart sounds, rhythm sounded regular. Tissue perfusion adequate.

Goal #1: Goal met. Continue plan.

KEISER COLLEGE – Melbourne, Florida Individual Nursing Care Plan Nursing Diagnosis Statement # : Risk for decreased cardiac output r/t altered heart rate/rhythm. Page 2 of 2

___ in the presence of alterations to tissue perfusion and cardiac output (Doenges, Moorhouse, & Murr, 2014. pp 92). 2. SHORT TERM GOAL:

2-1. Provide calm and quiet environment.

Client will participate in activities to reduce myocardial workload. 2-2. Demonstrate and encourage use of stress management behaviors such as relaxation techniques, guided imagery, and slow, deep breathing.

2.3. Encourage rest, semirecumbent in bed or chair.

Individual Nursing Care Plan 4/12

2-1. Reduces stimulation and release of stressrelated catecholamines, which can cause or aggravate dysrhythmias (Doenges, Moorhouse, & Murr, 2014. pp. 93).

Goal #2: Client discharged but I would have taught the client relaxation techniques, and deep breathing. Encouraged her to rest and provide a quiet environment to rest.

2-2. Promotes clients participation in exerting some sense of control in a stressful situation (Doenges, Moorhouse, & Murr, 2014. pp. 93). 2-3. Physical rest should be maintained to decrease myocardial workload (Doenges, Moorhouse, & Murr, 2014. pp. 49)

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KEISER COLLEGE – Melbourne, Florida Individual Nursing Care Plan Nursing Diagnosis Statement # : Risk for decreased cardiac output r/t altered heart rate/rhythm. Page 2 of 2

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Individual Nursing Care Plan 4/12

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