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Planning/Implementation/Evaluation
Med/Surg Nursing Diagnosis: Decreased cardiac output R/T Slow Heart Rate and insufficient blood supply to the body AEB increased BNP
Long-Term Goal: Patient cardiac output will improve
Outcome Criteria
Interventions
One outcome criteria for
each intervention.
Number each one.
Label each as
assess/monitor/independent/
dependent/teaching/collaboration
1. Patient will have
no peripheral edema
by 10/6/2014
1. Independent: Monitor edema q
shift
2. Patients heart rate
will be 60-100 bpm
when assessed
2. Independent: Assess heart rate
q 8 hours
3. Patient LOC will
not change during
each shift
3. Independent: Monitor changes
in LOC at all times
4. Patient BNP will
trend toward 0-99 by
10/6/2014
4. dependent: Monitor BNP as
ordered
Rationale
Evaluation
Answers why, how, what your interventions will help solve, prevent,
Or lesson the stated problem specific to each patient.
Evaluate the patient outcome,
NOT the intervention
1. Decreased cardiac output causes a backup of blood on the right
side of the heart which causes the blood to stay in the veins. The
outcome is peripheral edema. The patient is 92 years old and has a
decrease in her cardiac output. When she was admitted to hospital
she had bilateral lower extremity +1 pitting edema. Monitoring
peripheral edema will help determine if the cardiac output is
improving or getting worst.
2. The patient came into the emergency room with a heart rate of 36
BPM and was experiencing bradycardia. A normal heart rate is 60100 BPM. When the heart rate is this low, there is not enough
cardiac output to meet the demands of the body and a decrease in
tissue and organ perfusion. Symptoms of bradycardia are
hypotension, weakness, angina, dizziness or syncope, SOB, and cool
pale skin. She was weak, fatigued, and disorientated when she was
admitted. They eventually inserted a pacemaker to help keep her
heart rate above 60 BPM.
3. Restlessness, agitation and confusion are early signs of decrease
cerebral perfusion. When a patient’s cardiac output is decreased
there is not enough oxygenated blood in the brain. Determining a
baseline mental status is important for this patient because of the
dementia. Monitoring and noting any change in behavior will help
determine her cerebral perfusion.
4. B-Type natriuretic peptide (BNP) are hormones that are secreted in the
left ventricle of the heart. The level increase when the ventricles are
working harder to pump the blood through the body, which is known as left
ventricular dysfunction. It also helps determine if dyspnea is related to
cardiac problems. The higher the levels increase the more severe the heart
failure is. The patient’s BNP levels on 9/26/2014 during admission were 968
then increased to 1034 on 9/27/14, so it showed an increase in left
ventricle dysfunction. When a patient’s BNP are above 900 heart failure is
diagnosed as severe. Monitoring BNP will help determine if the left
1. Partially met. Her +1
pitting edema went down,
but she still had some.
2. Met. Her heart rate was
between 60-100 BPM during
my shift
3. Met. Her LOC did not
change during my shift
4. Not met. BNP where not
obtain during my shift
5. Patients Na+ 135145, Mg2+ 1.6-2.6
mg/dl, Ca 9-10.5
mg/dl, and K+ 3.5-5
mg/dl by 10/6/2014
5. Dependent: Monitor
electrolytes daily
6. Patients I/O will be
with 200 ml by
10/06/2014
6. Independent: Monitor I/O q
shift
7. Patient will have
no peripheral edema
by the end of Lasix
therapy
7. Dependent: Administer Lasix
20mg QD
8. Patient will have
no liver enlargement
or tenderness when
assessed.
8. Independent: Assess for
hepatomegaly q shift
9. Patient will have a
clear chest x-ray by
10/06/2014
9.Dependent: Monitor chest X-ray
when completed
10. Patient will
perform ADL’s
without fatigue each
day
10. Independent: Encourage rest
and activity periods daily
ventricle dysfunction is improving or getting worst.
5. Proper electrolyte balance of Na+, Ca, K+ and Mg are important for
cardiac output. A change in electrolyte levels could cause dysrhythmias
which could further decrease the patients cardiac output. Upon admission
the patient’s electrolyte levels where in normal limits, but they all
decreased due to the Lasix treatment. It is important to monitor any
changes in levels so you can properly correct them as soon as possible.
6. Monitoring intake and output is an important indicator of fluid
balance. If a person is taking in more fluid than they are excreting
and their cardiac output is low, it can exacerbate their peripheral
and pulmonary edema. The patient cardiac output is low she had
Bilateral lower extremities 1+ pitting edema and the chest x-rays
showed some pleural effusion in her right lung.
7. Lasix is important therapy for reducing edema and improving cardiac
output. By using Lasix there will be an increase in renal excretion of fluids.
Research has shown reducing fluids in the vascular system reduces the
patients preload by reducing the venous return. Reducing the preload will
allow the heart to work more efficiently by improving stroke volume and
increasing cardiac output. The patient was in fluid volume overload when
she was admitted, causing her to have a decreased cardiac output.
Therefore, the Lasix was prescribed.
8. When a person has heart failure and reduction in the venous
blood return it can cause blood and fluid to become backed up in the
body. The excess blood and fluid cause’s congestion in the liver. This
causes the liver to increase in side and become tender. The patient
was admitted with peripheral edema but did not have
hepatomegaly. By assessing for the development of hepatomegaly
you can assess if the heart failure treatment is working and or if
cardiac output is decreasing.
9. Chest x-rays are a way to monitor excess fluids in the lungs. When
a person has decreased cardiac output, the blood in the lungs gets
backed up causing pulmonary edema. When the patient was
admitted she already had some fluids in her lungs due to decrease
cardiac output. Monitoring chest x-rays will determine a shift in
cardiac output.
10. When a person has decreased cardiac output they are receiving a reduction in
oxygenated blood in their body. The decrease level of oxygen leaves the person
short of breath and fatigued. Having time to rest during activities will allow the
energy to perform their ADL. The patient is 92 years old, but still lives alone with the
help of a home nurse. It is important that she can accomplish as many of her ADL’s
independent as possible for her.
5.Not met: Her Na+ and Ca
where low on 10/3/2014
6. Partially met: she still had
edema and was on fluid
restriction. Her output was
greater than her intake.
7. Partially met: Her edema
was going down put she still
had some peripheral edema
8. Met: She had no signs of
hepatomegaly when
assessed
9. Not met: there were no
new chest x-ray during my
shift
10 Met: encouraged rest
when she was eating
11. Patient will not
have S3 and S4 heart
sounds when
assessed.
11. Independent: Assess heart
sounds for S3 and S4
11. A S3 heart sound occurs right after the S2. You hear it in adults when
12. Patients strength
will improve and she
will be able to
independently
perform more of her
ADL’s while in STR
13. Patient will
verbalize knowledge
of medication by
10/6/2014
12. Dependent: Collaborate with
Short-term rehab now
14. Patient will trend
towards clear when
assessed
14. Independent: assess lungs
sounds q 8 hrs
15. Patient will not
gain more than 1lb
daily.
15.Independent: Monitor patient
weight q day
16. Patients heart
rate will be between
60-100 bpm when
assessed
16. Dependent: Administer
Atropine 1mg q 6 hrs PRN
12. The patient is 92 years old with dementia and lives alone right
now. She has been in the hospital 9/26/14 and needs help in her
ADL’s right now. Short term rehab will help the patient recover from
her illness and improve her strength so she can perform her ADL’s
independently. They can also assess her for the need of skilled
nursing home placement.
13. Evidence based medicine has proven heart failure medications
reduce morbidly, mortality and improve patient’s quality of life. The
patient is 92 years old and has dementia which makes teaching
medication compliance even more important. Work with her home
nurse and daughter to educate on new or changes in current
medications. Give a list of each medication and how and when to
take them.
14. When cardiac output is decreased fluids back up in the lungs
causing fine crackles at the base of the lungs. Increased crackles is an
indication that the heart failure is worsening and cardiac output is
decreasing. Currently the patient lungs sounds are negative for
crackles. Assessing for the appearances of crackles would indicate
cardiac output is decreasing and the heart failure is worsening.
15. When a person gains more than 2 lbs in one day it is an
indication of fluid volume excess related to a decrease in cardiac
output. Weighing the patient daily will help determine if there is a
change in their fluid volume. The patient was admitted with
peripheral edema, so to determine if her cardiac output was
increasing she should lose any weight she has gained due to the
edema.
16. Atropine inhibits the action of acetylcholine at postganglionic
sites located the smooth muscle. This blocks the effects of the
parasympathetic nervous system and causes an increase in a
person’s heart rate. The patient heart rate was a 36 BPM when she
came into the emergency room and Atropine was prescribed if they
needed it to use to get her heart rate above 60 BPM.
13. Independent: Teach
medication compliance now
there is fluid volume overload in the ventricle that is usually caused by
heart failure. An S4 occurs right before the S1 and is caused by ventricle
hypertrophy which could be caused by coronary heart disease. Upon
admission the patient had a 3/6 systolic murmur over the aorta which was
caused by stenosis of the aorta. There were no S3 or S4 sound detected.
Assessing the heart sounds for S3 and S4 will help determine if there is an
increase in fluids or hypertrophy.
11. Met: there were no S3
or S4 during when
auscultating heart sounds.
12. partially met: working
on getting her placed in a
short term rehab
13. unmet: patient did not
verbalize medication
compliance
14. Partially met: patient
lung sounds where
diminished
15. Met: patient did not gain
weight.
16. Met: Patient heart rate
was 83 and 62
17. Patient K+ level
will be between 3.5-5
mEq/l while taking
Lasix.
17. Dependent: Administer
Potassium Chloride 30 mEq/l PO
TID
17. Potassium Chloride is prescribe to prevent the depletion of
potassium due to the Lasix the patient was receiving for her edema.
Potassium is an activator in many enzymatic reactions and is
essential to transmission of nerve impulses, and the contraction of
cardiac, skeletal, and smooth muscle cells. When the potassium level
falls below 3.5 mEq/l can develop dysrhythmia. It is important to
monitor her potassium daily so you know she is not being depleted
due to her Lasix therapy.
17 Met: on 10/3/14 her K+
level was 3.9 mEq/l
Psychosocial Need
Prioritized Psychosocial Nursing Diagnosis: Risk for anxiety R/T chronic illness
Long-Term Goal: Patients will not have an increased level of anxiety
Outcome Criteria
Interventions
One outcome criteria for
each intervention.
Number each one.
Label each as
assess/monitor/independent/
dependent/teaching/collaboration
1. Patient HR 60-100,
BP 120/80, no
diaphoresis and body
or facial tension
when assessed
1. Independent: assess patients
level of anxiety q shift
2. Patient anxiety
level will remain low
when interacting
with her
2. Independent: Maintain a calm
manner while interacting with the
patient
3. Patient room will
be quiet and stimuli
free at all times
3. Independent: Maintain a quiet
environment at all times.
4. Patient will discuss
feelings she
experiencing
increased feelings of
anxiety
4. Independent: practice active
listening when interacting with
the patient.
Rationale
Evaluation
Answers why, how, what your interventions will help solve, prevent,
Or lesson the stated problem specific to each patient.
Evaluate the patient outcome,
NOT the intervention
1. When a patient’s level of anxiety increases they start to have
physical changes. You can see a change in their HR, BP, diaphoresis,
and facial and body tension. This happens because of the fight or
flight response of the sympathetic nervous system. The patient was
recently living at home and now she has to adjust to the hospital
environment. This could increase her anxiety level. Assessing an
increase in her anxiety level and treating it would help to control her
anxiety level.
2. A patient can sense when a nurse is stressed and is experiencing
their own anxiety. This can be projected to the patient and increase
their own anxiety. The patient experienced fecal incontinence and
she verbalized slight anxiety because of it. Keeping a calm manner
helped her keep her anxiety to a minimum.
3. Anxiety can increase with excessive noise and stimuli that seems
to go hand in hand with hospitalizations. The patient is used to living
in a quiet environment, so the increase noise and stimuli in a
hospital could increase her anxiety. Keep voices, noises and stimuli
to minimum will help keep her anxiety down.
4. A very important part of the nurse- patient therapeutic
relationship is active listening. The patient is 92 years old and
expressed feelings of boredom and being scared. Stopping what you
are doing and just listen to her express her feeling and fears without
judgment or opinions will help keep her anxiety level low.
1. Met: Patient’s HR, BP
remained between 60-100
and BP 106/70 when
assessed
2. Partially met: I tried to
keep a calm manner when I
was interacting with her,
but I’m not sure I
succeeded.
3. Partially met: There were
a lot of people going in and
out of the room. I tried to
keep other stimuli to a
minimum.
4. Met: I took the time to
listen to her when she was
expressing her feelings