Nursing Diagnosis: Decreased Cardiac output Application of NANDA, NOC, NIC

Nursing Diagnosis: Decreased Cardiac output
Linda L. Straight and Betty J. Ackley

NANDA Definition: Inadequate blood pumped by the heart to meet metabolic demands of the body

Defining Characteristics: Altered heart rate/rhythm: arrhythmias (tachycardia, bradycardia); palpitations; EKG changes; altered preload: jugular vein distention; fatigue; edema; murmurs; increased/decreased central venous pressure (CVP); increased/decreased pulmonary artery wedge pressure (PAWP); weight gain; altered afterload: cold/clammy skin; shortness of breath/dyspnea; oliguria; prolonged capillary refill; decreased peripheral pulses; variations in blood pressure readings; increased/decreased systemic vascular resistance (SVR); increased/decreased pulmonary vascular resistance (PVR); skin color changes; altered contractility: crackles; cough; orthopnea/paroxysmal nocturnal dyspnea; 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; behavioral/emotional: anxiety; restlessness

Related Factors: Myocardial infarction or ischemia, valvular disease, cardiomyopathy, serious dysrhythmia, ventricular damage, altered preload or afterload, pericarditis, sepsis, congenital heart defects, vagal stimulation, stress, anaphylaxis, cardiac tamponade

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Cardiac Pump Effectiveness

·         Circulatory Status

·         Tissue Perfusion: Abdominal Organs

·         Tissue Perfusion: Peripheral

·         Vital Signs Status

Client Outcomes

·         Demonstrates adequate cardiac output as evidenced by BP and pulse rate and rhythm within normal parameters for client; strong peripheral pulses; and an ability to tolerate activity without symptoms of dyspnea, syncope, or chest pain

·         Remains free of side effects from the medications used to achieve adequate cardiac output

·         Explains actions and precautions to take for cardiac disease

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Cardiac Care: Acute

·         Circulatory Care

Nursing Interventions and Rationales

·         Monitor for symptoms of heart failure and decreased cardiac output, including diminished quality of peripheral pulses, cool skin and extremities, increased respiratory rate, presence of paroxysmal nocturnal dyspnea or orthopnea, increased heart rate, neck vein distention, decreased level of consciousness, and presence of edema. As these symptoms of heart failure progress, cardiac output declines (Murphy, Bennett, 1992; Ahrens, 1995).

·         Listen to heart sounds; note rate, rhythm, presence of S3, S4, and lung sounds (noting presence of crackles). The new onset of a gallop rhythm, tachycardia, and fine crackles in lung bases can indicate onset of heart failure (Janowski, 1996). If client develops pulmonary edema, there will be coarse crackles on inspiration and severe dyspnea.

·         Observe for confusion, restlessness, agitation, dizziness. Central nervous system disturbances may be noted with decreased cardiac output (Alspach, 1998).

·         Observe for chest pain or discomfort; note location, radiation, severity, quality, duration, associated manifestations such as nausea, and precipitating and relieving factors. Chest pain/discomfort is generally indicative of an inadequate blood supply to the heart, which can compromise cardiac output. Clients with heart failure can continue to have chest pain with angina or can reinfarct.

·         If chest pain is present, have client lie down, monitor cardiac rhythm, give oxygen, run a strip, medicate for pain, and notify the physician. These actions can increase oxygen delivery to the coronary arteries and improve client prognosis.

·         Place on cardiac monitor; monitor for dysrhythmias, especially atrial fibrillation. Atrial fibrillation is common in heart failure (Janowski, 1996).

·         Monitor hemodynamic parameters for an increase in pulmonary wedge pressure, an increase in systemic vascular resistance, or a decrease in cardiac output and index. Hemodynamic parameters give a good indication of cardiac function.

·         Titrate inotropic and vasoactive medications within defined parameters to maintain contractility, preload, and afterload per physician's order. By following parameters, the nurse ensures maintenance of a delicate balance of medications that stimulate the heart to increase contractility, maintaining adequate perfusion of the body.

·         Monitor intake and output. If client is acutely ill, measure hourly urine output and note decreases in output. Decreased cardiac output results in decreased perfusion of the kidneys, with a resulting decrease in urine output.

·         Note results of EKG and chest Xray. EKG can reveal previous MI,or evidence of left ventricular hypertrophy, indicating aortic stenosis or chronic systemic hypertension. Xray may provide information on pulmonary edema, pleural effusions, or enlarged cardiac silhouette found in dilated cardiomyopathy or large pericardial effusion.(Hurst)

·         Note results of diagnostic imaging studies such as echocardiogram, radionuclide imaging or dobutamine stress echocardiography. The echocardiogram is the most important imaging tool for evaluation patients with symptoms of heart failure because overall systolic function and chamber size can be evaluated quickly. In addition, global versus regional left ventricular function, valvular abnormalities, and diastolic function can be defined, assisting in differential diagnosis. (Hurst, 2000). An ejection fraction in a healthy heart is approximately 50%. Most patients experiencing heart failure have an ejection fraction of less than 40% (Janowski, 1996).

·         Watch laboratory data closely, especially arterial blood gases and electrolytes, including potassium. Client may be receiving cardiac glycosides and the potential for toxicity is greater with hypokalemia; hypokalemia is common in heart clients because of diuretic use (Lessig, Lessig, 1998).

·         Monitor lab work such as complete blood count, sodium level, and serum creatinine. Routine blood work can provide insight into the etiology of heart failure and extent of decompensation. A low serum sodium level often is observed with advanced heart failure and can bea poor prognostic sign.(Hurst) Serum creatinine levels will elevate in clients with severe heart failure because of decreased perfusion to the kidneys.Creatinine may also elevate because of ACE inhibitors (Ahrens, 1995)

·         Administer oxygen as needed per physician's order. "Supplemental oxygen increases oxygen availability to the myocardium" (Prizant-Weston, Castiglia, 1992).

·         Place client in semi-Fowler's position or position of comfort. Elevating the head of the bed may decrease the work of breathing, and also decrease venous return and preload.

·         Check blood pressure, pulse, and condition before administering cardiac medications such as angiotensin converting enzyme (ACE) inhibitors, digoxin, and beta-blockers such as carvedilol. Notify physician if heart rate or blood pressure is low before holding medications. It is important that the nurse evaluate how well the client is tolerating current medications before administering cardiac medications; do not hold medications without physician input. The physician may decide to have medications administered even though the blood pressure or pulse rate has lowered.

·         During acute events, ensure client remains on bed rest or maintains activity level that does not compromise cardiac output. In severe heart failure, restriction of activity often facilitates temporary recompensation (Massie, Amidon, 1998).

·         Gradually increase activity when client's condition is stabilized by encouraging slower paced activities or shorter periods of activity with frequent rest periods following exercise prescription; observe for symptoms of intolerance. Take blood pressure and pulse before and after activity and note changes. Activity of the cardiac client should be closely monitored. See Activity intolerance.

·         Serve small sodium-restricted, low-cholesterol meals. Give only small amounts of caffeine-containing beverages (1 or 2 cups per 24 hours) if no resulting dysrhythmia. Sodium-restricted diets help decrease fluid volume excess. Low-cholesterol diets help decrease atherosclerosis, which causes coronary artery disease. Clients with cardiac disease tolerate smaller meals better because they require less cardiac output to digest. One cup of caffeinated coffee has generally not been found to have any significant effect (Schneider, 1987; Powell, 1993).

·         Monitor bowel function. Provide stool softeners as ordered. Caution client not to strain when defecating. Decreased activity can cause constipation. Straining when defecating that results in the Valsalva maneuver can lead to dysrhythmia, decreased cardiac function, and sometimes death.

·         Have clients use a commode or urinal for toileting and avoid use of a bedpan. Getting out of bed to use a commode or urinal does not stress the heart any more than staying in bed to toilet. In addition, getting the client out of bed minimizes complications of immobility and is often preferred by the client (Winslow, 1992).

·         Provide a restful environment by minimizing controllable stressors and unnecessary disturbances. Schedule rest periods after meals and activities. Rest periods decrease oxygen consumption (Prizant-Weston, Castiglia, 1992).

·         Weigh client at same time daily (after voiding). An accurate daily weight is a good indicator of fluid balance. Increased weight and severity of symptoms can signal decreased cardiac function with retention of fluids.

·         Assess for presence of anxiety; see interventions for Anxiety to facilitate reduction of anxiety in clients and family.

·         Consider using music to decrease anxiety and improve cardiac function. Music has been shown to reduce heart rate, blood pressure, anxiety, and cardiac complications (Guzzetta, 1994).

·         Closely monitor fluid intake including IV lines. Maintain fluid restriction if ordered. In clients with decreased cardiac output, poorly functioning ventricles may not tolerate increased fluid volumes.

·         Refer to heart failure program or cardiac rehabilitation program for education, evaluation, and guided support to increase activity and rebuild life. Exercise can help many patients with heart failure. Whereas rest was commonly recommended a few years ago, it has become clear that inactivity can worsen the skeletal muscle myopathy in these patients.A carefully monitored exercise program can improve both functional capacity (Bellardinelli et al, 1999)and left ventricular function (Giuanuzzi et al, 1997)Exercise based cardiac rehabilitation programs apppear to be effective in reducing cardiac deaths, but the evidence base is weakened by poor quality trials (Jolliffe et al, 2000)

Geriatric

·         Observe for atypical pain; the elderly often have jaw pain instead of chest pain or may have silent myocardial infarctions with symptoms of dyspnea or fatigue. The elderly have altered pain pathways and often do not experience the usual chest pain of cardiac patients (Carnevali, Patrick, 1993).

·         Observe for syncope, dizziness, palpitations, or feelings of weakness associated with a irregular heart rhythm. Dysrhythmias are common in the elderly (Carnevali, Patrick, 1993).

·         Observe for side effects from cardiac medications. The elderly have difficulty with metabolism and excretion of medications due to decreased function of the liver and kidneys; therefore toxic side effects are more common.

Home Care Interventions

·         Begin discharge planning as soon as possible with case manager or social worker to assess home support systems and the need for community or home health services. These may be to assist with home care, assistance with meal perparations, housekeeping, personal care, transportation to doctor visits, or emotional support. Clients often need help upon discharge. The existing social support network needs to be assessed and assistance provided as needed to meet client needs and to keep the support persons from being overwhelmed (Campbell, 1998). Being discharged to home without adequate support has been shown to be related to readmission of elderly patients (Jaarsma, 1996).

·         Assess or refer to case manager or social worker to evaluate client ability to pay for prescriptions. The cost of drugs may be a factor to fill prescriptions and adhere to a treatment plan (Campbell, 1998).

·         Continue to monitor client for exacerbation of heart failure when discharged home. Transition to home can create increased stress and physiological instability related to diagnosis.

·         Assess client for understanding and compliance with medical regimen, including medications, activity level, and diet.

·         Instruct family and client about the disease process, complications of disease process, information on medications, need for weighing daily, and when it is appropriate to call doctor. Early recognition of symptoms facilitates early problem solving and prompt treatment (Janowski, 1996). Clients with heart failure need intensive guideline gased education about these topics to help prevent readmission to the hospital (Moser, 199?)

·         Identify emergency plan, including use of CPR. Decreased cardiac output can be life threatening.

·         Help family adapt daily living patterns to establish life changes that will maintain improved cardiac functioning in the client. Transition to the home setting can cause risk factors such as inappropriate diet to reemerge.

·         Refer to physical therapy for strengthening exercises if client is not involved in cardiac rehabilitation.

·         Refer to medical social services as necessary for counseling about the impact of severe or chronic cardiac disease. Social workers can assist the client and family with acceptance of life changes.

Client/Family Teaching

·         Teach symptoms of heart failure and appropriate actions to take if client becomes symptomatic.

·         Teach importance of smoking cessation and avoidance of alcohol intake. Clients who continue to smoke increase their chance of dying by at least 50%, and alcohol depresses heart contractility (Janowski, 1996). Smoking cessation advice and counsel given by nurses can be effective, and should be available to clients to help stop smoking (Rice & Stead, 2000).

·         Teach stress reduction (e.g., imagery, controlled breathing, muscle relaxation techniques).

·         Explain necessary restrictions, including consumption of a sodium-restricted diet, guidelines on fluid intake, and the avoidance of Valsalva's maneuver. Teach the importance of pacing activities, work simplification techniques, and the need to rest between activities to prevent becoming overly fatigued. Sodium retentiion leading to fluid overload is a common cause of hospital readmission (Bennett et al, 2000).

·         Assist client in understanding the need for and how to incorporate lifestyle changes. Refer to cardiac rehabilitation for assistance with coping and adjustment. Psychoeducational programs including information on stress management and health education have been shown to reduce long term mortality and recurrence of myocardial infarction in heart patients (Benson, 1999)

·         Teach client actions, side effects, and importance of consistently taking cardiovascular medications. Medications can prolong the lives of heart failure clients but often are not taken, resulting in hospital readmissions (Agency for Health Care Policy and Research).

·         Provide client/family with advance directive information to consider. Allow client to give advance directions about medical care or designates who should make medical decisions if he or she should lose decision-making capacity (Alspach, 1998).

·         Instruct client on importance of getting a pneumonia shot (usually one per lifetime) and yearly flu shots as prescribed by physician. Clients with decreased cardiac output are considered higher risk for complications or death if they do not get immunization injections.

·         Instruct client/family on the need to weigh daily and keep a weight log. Ask if client has a scale at home; if not, assist in getting one. Instruct on establishing baseline weight on own scale when gets home. Weighing daily is an essential aspect of self-management. A scale is necessary (Campbell, 1998). Scales vary and the client needs to establish a baseline weight on their home scale.

·         Provide specific written materials and self-care plan for client/caregivers to use for reference. Consult dietitian or assist client in understanding the need for a sodium-restricted diet. Provide alternatives for salt such as spices, herbs, lemon juice, or vinegar. Although the initial elimination of salt from the diet is very difficult for a person use to its taste, the taste of salt can be unlearned. The above can enhance the taste appeal of food while the preference for salt is changing (Peckenpaugh, Poleman, 1999).

·         Instruct family regarding cardiopulmonary resuscitation.