PLANNING/IMPLEMENTING/EVALUATION (See Grading Rubric for NCP Criteria) Nursing Diagnosis Risk for decreased cardiac output r/t

abnormal heart rhythm, contractility and excess fluid volume. Long Term Goal Pt will maintain adequate cardiac output.

Outcome Criteria
One-outcome criteria for each intervention. Number each one. 1. Pt will maintain baseline VS as assessed Q2h. (SBP<180 >90 DBP <90 >50 O2 sat >92%RA AP <120 >60 Resp <20 <10 and temp <101.0.

Interventions
Label each intervention as: Assess/Monitor/Independent/ Dependent/Teaching/Collaboration 1.Assess VS Q4hrs and PRN. Independent.

Rationale
Answers why, how, what your intervention will help solve, prevent or lessen the stated problem specific to this patient. 1. This was admitted with CHF, new onset A-fib heart rate was noted to be ~107. His c/c was SOB. Frequent monitoring of VS is indicated to monitor condition and observe trends in VS indicating a change in his condition. HF can have an abrupt onset as with acute MI and Afib, or it can be an insidious process resulting from slow, progressive changes. The overloaded heart resorts to compensatory mechanisms to try to maintain adequate CO. The SNS is often the first compensatory mechanism activated marked by increased release of catecholamine, resulting in increased HR, increased myocardial contractility and peripheral vasoconstriction. Lewis 798-799. Hypotension would indicate decreased cardiac output and the body would compensate by increasing RR and HR to increase oxygen availability. A decrease in the O2 level could indicate pulmonary edema and fluid in the alveoli. With A-fib the heart rate is elevated, but the amount of blood that is pumped can be decreased by up to 30%. This pt.s VS stayed within parameters and he exhibited no s/s of decreased cardiac output.

Evaluation
Evaluate the patient outcome; NOT the intervention. 1. Met.

Outcome Criteria
One-outcome criteria for each intervention. Number each one.

Interventions
Label each intervention as: Assess/Monitor/Independent/ Dependent/Teaching/Collaboration 2.Assess LS Q2h and PRN. Independent.

Rationale
Answers why, how, what your intervention will help solve, prevent or lessen the stated problem specific to this patient.

Evaluation
Evaluate the patient outcome; NOT the intervention.

2.Pts LS will remain clear as assessed Q2h and PRN.

2.This pt was admitted w/ CHF and new onset A-fib and presented to the ER w/ a c/c of SOB. The most common form of HF is leftsided failure and results from ventricular dysfunction, which prevents normal blood flow and cause blood to back up into the left atrium and into the pulmonary veins. The increased pulmonary pressure causes fluid extravasation from the pulmonary

2. Met

capillary bed into the interstitium and then the alveoli, which manifests as pulmonary congestion and edema. This pt has marked aortic, mitral and tricuspid valve insufficiencies that will cause blood to flow backwards. This pt lost 16.5 lbs. of fluid from admission on 12.2 to 12/6. During chest auscultation, instruct the t to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless it is possible the patient will tire; if so, one should start at the bases. Listen to at least one cycle of inspiration and expiration. Note the pitch, duration of sound, and presence of adventitious or abnormal sounds. Lewis 509510. The presence of crackles could signify interstitial edema, early pulmonary edema, alveolar filling, pneumonia, loss of lung volume, and atelectasis. Lewis 511. Auscultating lung sounds every 2hrs will allow the health care team to intervene quickly on changes. Ackley 402 Assessing LS frequently will help identify if the fluid is pooling in lung fields and reflecting decreased cardiac output. Lewis 800.

Outcome Criteria
One-outcome criteria for each intervention. Number each one.

Interventions
Label each intervention as: Assess/Monitor/Independent/ Dependent/Teaching/Collaboration 3.Assess wt. Qday. Independent.

Rationale
Answers why, how, what your intervention will help solve, prevent or lessen the stated problem specific to this patient. 3. This pt was admitted with CHF and A-fib. 2.2 pounds or 1 kg equals 1 liter of fluid -Lecture. An accurate weight requires the pt. to be weighed at the same time every day, wearing the same garments and on the same carefully calibrated scale Lewis 310. This helps ensure valid comparisons from day to day and helps identify early sign of fluid retention. Lewis 808. This pt lost 16.5 lbs. from 12/2 to 12/6, which is 7.5 kg or 7,500mL. With HF there is a progressive weight gain from fluid retention. Lewis 802. 25% of blood flow goes to the kidney or 1,200mL/min. An increase in weight can signify a decrease in cardiac function via decreased kidney perfusion, which and cause the body to retain fluids leading to rapid weight gain. 4. Cerebral circulation may be impaired with HF secondary to decreased CO. The patient or caregiver may report unusual behavior, including restlessness, confusion and decreased attention span or memory. This may also be secondary to poor gas exchange and worsening HF. Lewis 802. Noticing a change in this pt.s LOC could indicate decrease CO as the brain is a vital organ and blood will always be shunted to vital organs.

Evaluation
Evaluate the patient outcome; NOT the intervention.

3. Pt will verbalize the need to call MD for wt. gain of 2 lbs. in 2 days after 1:1 session.

3. Met.

4. Pt will remain A&OX3 as assessed Q4h.

4.Assess LOC Q4h. Independent.

4. Met.

Outcome Criteria
One-outcome criteria for each intervention. Number each one. 5. Pt.s troponin 1 will trend to < 0.05ng/mL as assessed during hospitalization.

Interventions
Label each intervention as: Assess/Monitor/Independent/ Dependent/Teaching/Collaboration 5.Draw serial Troponin 1 levels Q6h x24hours. Dependent.

Rationale
Answers why, how, what your intervention will help solve, prevent or lessen the stated problem specific to this patient. 5. Troponin is a complex of three contractile proteins that regulate the interaction of actin and myosin. Troponin 1 is a protein released into the blood by damaged heart muscle, but not skeletal muscle, and therefore is a highly sensitive and specific indicator of heart tissue damage. This pt was admitted with CHF and A-fib. His troponin 1 level was in the grey area 0.11 and peaked at 0.13ng/mL. This pt had approx. 7,500ML of excess fluid in his body; this caused strain on his heart causing the elevated troponin level. This test is normally ordered for MIs but it does indicate cardiac tissue damage and cardiac tissue damage will lead to decreased cardiac output. Nursing central. 6. This pt was admitted w/ CHF and new onset of A-fib, his AP was noted around 107 and irregular. A-fib and an irregular HR will decrease CO. Digoxin is an antiarrhythmic and inotrope. It is used for both HF and A-fib. It works by increasing the force of myocardial contraction, it prolongs refractory period of the AV node and decreases conduction through the SA and AV nodes; a therapeutic effect is increased cardiac output. This pt.s dig level was noted to be 1.6, 2.0 and 1.5. Digoxin has a very therapeutic index therefore it has a high risk for toxicity careful laboratory monitoring is needed for this high-risk drug. This pt was on telemetry and his EKG was read as NSR w/ 1st degree HB. His AP was around 60-70. This information shows the nurse that his new onset A-fib is controlled w/ current medication interventions. Side effects of Digoxin are: arrhythmias, bradycardia, AV block and SA block. Monitoring the lab level for this medication will evaluate its effectiveness and desired increased CO and potential complications such as heart block, which if the heart rate drops too low; <60bpm will indicate decreased CO. Nursing central.

Evaluation
Evaluate the patient outcome; NOT the intervention. 5.Partially met, lab results peaked at 0.13 and decreased to 0.11 .

6. Pt.s digoxin level will be 0.52.0ng/mL as assessed during hospitalization.

6. Draw digoxin levels Qday. Dependent.

6. Met.

Outcome Criteria
One-outcome criteria for each intervention. Number each one. 7.Pts BNP will trend towards normal; <100pg/mL as assessed during hospitalization.

Interventions
Label each intervention as: Assess/Monitor/Independent/ Dependent/Teaching/Collaboration 7. Draw BNP QdayX2. Dependent.

Rationale
Answers why, how, what your intervention will help solve, prevent or lessen the stated problem specific to this patient. 7.BNP is Brain natriuretic peptide it is an antagonist of the renin-angiotensinaldosterone system, which assists in the regulation of electrolytes, fluid balance, and blood pressure. It is used to assist in diagnosing congestive heart failure. A value of <100pg/mL is considered normal. It is a neurohormone synthesized primarily in the ventricles of the human heart in response to increases in ventricular pressure and volume. Circulating levels of BNP increase in proportion to the severity of HF. In general Bnp levels correlate positively with the degree of left ventricular dysfunction. Lewis 803. This pt.s BNP was 1,144 upon admission and decreased to 939. This pt.s BNP decreased which shows improving L ventricular function, CHF, decreased fluid retention which shows improved CO. Nursing central. 8. This pt was admitted w/ CHF and new onset of A-fib, his AP was noted around 107 and irregular. Chronic HF causes enlargement of the chambers of the heart. This enlargement may cause an alteration in the normal electrical pathway, especially in the atria. This pt was noted to have left and right atria dilation. When numerous sites in the atria fire spontaneously and rapidly the organized spread of atrial depolarization no longer occurs. Lewis 802. A-fib and an irregular HR will decrease CO. Digoxin is an antiarrhythmic and inotrope. It is used for both HF and A-fib. It works by increasing the force of myocardial contraction, it prolongs refractory period of the AV node and decreases conduction through the SA and AV nodes; a therapeutic effect is increased cardiac output. CO increases because of an increased stroke volume from improved contractility. Lewis 807. This pt was on telemetry and his EKG was read as NSR w/ 1st degree HB. His AP was around 60-70. This information shows the nurse that his new onset A-fib is controlled w/ current medication interventions. Giving this medication will evaluate its effectiveness and desired increased CO and potential complications such as heart block, which if the heart rate drops too low; <60bpm will indicate decreased CO. Nursing central.

Evaluation
Evaluate the patient outcome; NOT the intervention. 7. Partially met. A repeat BNP should have been drawn.

8. Pt.s AP will remain between 60-100bpm as assessed during hospitalization.

8.Adminsiter Digoxin 0.125mg PO before lunch; hold for AP <60. Dependent.

8. Met.

Outcome Criteria
One-outcome criteria for each intervention. Number each one. 9. Pt will remain free from SOB during hospitalization.

Interventions
Label each intervention as: Assess/Monitor/Independent/ Dependent/Teaching/Collaboration 9. Administer Lasix 20mg PO Qday. Dependent.

Rationale
Answers why, how, what your intervention will help solve, prevent or lessen the stated problem specific to this patient. 9. This pt was admitted w/ CHF. He had no adventitious LS, or edema only c/o SOB. Lasix is a loop diuretic, it works by inhibiting the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. It increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium. It decreases BP, vascular volume and preload. Decreasing venous return or preload reduces the amount of volume returned to the LV during diastole, causing the LV to contract more efficiently and decreases pulmonary vascular pressures, and improves gas exchange and CO. Lewis 804. This pt lost 16.5 lbs. of fluid he was on 40mg of Lasix upon admission until 12/6 when it was lowered to 20mg; giving this Lasix helped him to diuresis all the excess fluid that was cause of his initial c/o of SOB thereby solving the initial problem and subsequently increasing his cardiac output. Nursing central. Lewis 804 & 806.

Evaluation
Evaluate the patient outcome; NOT the intervention. 9. Met.

10. Pt.s BP will remain between 180/90 and 90/50 as assessed during hospitalization.

10. Ramipril 5mg PO Qday. Dependent.

10. Ramipril is an angiotensin-converting enzyme inhibitor. ACE-I block the conversion of angiotensin1 to the vasoconstrictor angiotensin 2. ACE-I also prevents the degradation of bradykinin and other vasodilatory prostaglandins. ACE-I also increases plasma renin levels and decrease aldosterone levels, net result is systemic vasodilation. ACE-I are considered neurohormonal blocking agents and they decrease the development of ventricular remodeling by inhibiting ventricular hypertrophy. This pt has HTN, new onset A-fib and CHF; the decrease in systemic vascular resistance seen with the use of ACE-I produce a significant increase in CO. Nursing central. Lewis 807.

10. Met.

11.Pts AP will remain between 60-100 as assessed during hospitalization.

11. Toprol XL 50mg PO Qday. Dependent.

11. Toprol XL is antihypertensive and a beta-blocker. It can be used for symptomatic HF along with ACE-I, diuretics and/or digoxin; Toprol XL ONLY. This pt has HTN A-fib and CHF. It works by blocking the stimulation of beta-1 adrenergic receptors; myocardial. It decreases BP and HR. It works by decreasing the afterload which will decrease the preload indirectly. Decreasing the preload reduces the amount of blood returned to the LV allowing it to contract more efficiently; increasing CO.

11. Met.

Outcome Criteria
One-outcome criteria for each intervention. Number each one. 12. Pt will maintain wt. 120lbs as assessed Qday during hospitalization.

Interventions
Label each intervention as: Assess/Monitor/Independent/ Dependent/Teaching/Collaboration 12. Aldactone 25mg PO Qday. Dependent.

Rationale
Answers why, how, what your intervention will help solve, prevent or lessen the stated problem specific to this patient. 12. Aldactone is a potassium-sparing diuretic. Its used to HTN and edema associated with HF both of which this pt has. It works by causing losses of sodium bicarbonate and calcium while saving potassium and hydrogen ions by antagonizing aldosterone, per the drug guide this medication has increased survival in pt.s with severe HF (NY Heart Association class II -IV). Nursing central. This medication is ordered to help diuresis addition fluid in this pt. This pt lost 16.5 lbs. in 5 days. This medication works differently by sparing potassium; which is needed for heart function and hypokalemia will cause his digoxin levels to increase and become toxic. Lecture. Helping to pull off excess fluid will decrease preload and help the heart contract more effectively; increasing cardiac output. 13. This pt was admitted with CHF and new onset of A-fib his HR was noted to be ~107. He is on Digoxin and Toprol; two medications that both decrease his HR to promote CO. Bradycardia is a HR <60. This pt is going home on these medications and needs to know these side effects to have a safe d/c. During clinical his HR was noted to be ~60-70 and NSR w/ 1st degree HB. CO is measure by stroke volume multiplied by HR therefore if his HR drops too low so will his cardiac output. Lecture.

Evaluation
Evaluate the patient outcome; NOT the intervention. 12. Met.

13.Pt will demonstrate proper technique to take radial pulse after 1:1 session.

13. Teach pt how to take radial pulse during 1:1 session.

13. Partially met. Pt kept counting a HR of 60, more education needed.

14. Pt will demonstrate EF of 5070% as assessed per echocardiogram.

14. Echocardiogram X1 upon admission. Dependent.

14.An echocardiogram is a noninvasive test that uses ultrasound to visualize cardiac structures and functions including the hearts chambers, ejection fraction, valves, and wall motion can be evaluated, and intracardiac masses or clots can often be seen. This study can also determine blood-flow velocity and direction and the presence of pericardial effusion during the movement of the transducer over areas of the chest. Lewis 730. This pt has a previous echo done in May and his EF was 65%. The echo done during this hospitalization showed an EF of 60% (a decrease of 5% in 6 months.) The echo also showed both atria dilatation, aortic valve insufficiency, severe mitral valve insufficiency, and moderate tricuspid valve insufficiency. This is a rapid diagnostic tool to assess for any cardiac changes that could indicate a need for prompt intervention and this test indicated this pt is having adequate CO.

14. Met.

Outcome Criteria
One-outcome criteria for each intervention. Number each one. 15. Pts I/O will be equal as assessed Q8h.

Interventions
Label each intervention as: Assess/Monitor/Independent/ Dependent/Teaching/Collaboration 15. Assess I/O Q8h. Independent.

Rationale
Answers why, how, what your intervention will help solve, prevent or lessen the stated problem specific to this patient.

Evaluation
Evaluate the patient outcome; NOT the intervention. 15. Met.

15. The use of 24 hr. intake/output records gives valuable information regarding fluid and electrolyte problems, and allows the health care provider to assess for cardiovascular changes. Intake should include oral and IV fluids. Output should include urine, excessive perspirations, wound or tube drainage, vomitus and diarrhea. Fluid loss from wounds and perspiration should be estimated. Lewis 310. A urine output of less than 30ml/hr. is insufficient for good renal function and indicates hypervolemia or onset of renal damage. The reduced amount of urine indicates a reduced fluid volume in the body and vascular volume. NDH 390. Elevated fluid volume levels are a sign of CHF. Ackley 633. Blood flow to the kidneys is approx.. 25% of the cardiac output equaling 1,200mL/min. Lewis 1105. Monitoring I/O will indicate fluid volume by intakes, and the characteristics of urine production which mirrors kidney blood flow which accounts for a 1/4 th of the hearts pumping ability indicating adequate CO. This pt lost 16.5 lbs. from 12/2 to 12/6. This weight loss was primarily water weight and indicates adequate CO.

Sources Ackley, B. J., & Ladwig, B. G. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9 ed.). St. Louis, MO: Mosby Elsevier. Lewis, S., & et al. (2011). Medical-surgical nursing: Assessment and management of clinical problems (8th). St. Louis, MO: Mosby Elsevier.