- Actual
- Risk for (Potential)
Related To: [Check those that apply]
- Increased or decreased ventricular filling (preload)
- Alteration in afterload
- Impaired contractility
- Alteration in heart rate, rhythm, and conduction
- Decreased oxygenation
- Cardiac muscle disease
As evidenced by: [Check those that apply]
- Variations in hemodynamic parameters (blood pressure [BP], heart rate, cardiovascular pressure [CVP], pulmonary artery pressures, venous oxygen saturation [S VO2], 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
- Angina
- Ejection fraction less than 40%
- Pulsus alternans
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Patient’s Diagnosis: –
Date:-
- maintains BP within normal limits; warm, dry skin; regular cardiac rhythm; clear lung sounds; and strong bilateral, equal peripheral pulses.
- Others
Note: you need to indicate time frame/target as objective must be measurable.
| Nursing Interventions | Scientific Rationale |
|---|---|
| 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. |
| 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 urine output. Determine how often the patient urinates. | Oliguria can reflect decreased renal perfusion. Diuresis is expected with diuretic therapy. |
| Assess for chest pain. | Indicates an imbalance between oxygen supply and demand. |
| Maintain optimal fluid balance. | 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. |
| 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. |
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