PATIENT’S NAME: MELINDA JAFFE AGE: 28 YEARS OLD MARITAL STATUS: MARRIED

DIAGNOSIS: DECREASE CARDIAC OUTPUT DUE TO CONGESTIVE HEART FAILURE

CUES/DATA NURSING NURSING GOAL NURSING RATIONALE EVALUATION
DIAGNOSIS AND OBJECTIVES INTERVENTIONS
Subjective: Decreased Cardiac  Patients 1. Record intake 1. Reduced  The goals
“Mag lisod kog Output related to demonstrates and output. If cardiac output establish are
ginhawa usahay unya alteration in heart adequate patient is results in met which
huot ahong dughan rate, rhythm, and cardiac output acutely ill, reduced indicates that
labi nag mahago ko” conduction, cardiac as evidenced measure perfusion of the patient can
as verbalized by the muscle disease, by blood hourly urine the kidneys, now
patient decrease in pressure and output and with a demonstrate
oxygenation, pulse rate and note decreases resulting adequate
Objective: impaired contractility, rhythm within in output decrease in cardiac output
 Facial increased afterload, normal 2. For patient urine output. as evidenced
Grimacing increased or parameters for with increased 2. Fluid by blood
 Restlessness decreased ventricular patient; strong preload, limit restriction pressure and
 Abnormal filling (preload) peripheral fluids and decreases pulse rate and
Heart Sounds pulses; and an sodium as extracellular rhythm within
 V/s taken a Scientific Basis: ability to ordered fluid volume normal
follows: Decreased cardiac tolerate 3. Closely and reduces parameters for
T: 37.5°C output is an often- activity monitor fluid demands on patient; strong
PR: 40 bpm serious medical without intake the heart. peripheral
RR: 40 cpm condition that occurs symptoms of including IV 3. In patients pulses; and an
BP: 140/90 mmHg when the heart does dyspnea, lines. with ability to
not pump enough syncope, or Maintain fluid decreased tolerate
 Pain Scale of blood to meet the chest pain. restriction if cardiac output, activity
7/10 (0 as the needs of the body. It  Patient exhibit ordered. poorly without
lowest and 10 can be caused by warm, dry 4. Auscultate functioning symptoms of
as the highest) multiple factors, some skin, eupnea heart sounds; ventricles may dyspnea,
of which with absence note rate, not tolerate syncope, or
include heart disease, of pulmonary rhythm, increased fluid chest pain.
congenital heart defec crackles presence of volumes.  Patients
ts, and low blood  Patient S3, S4, and 4. The new onset exhibits warm,
pressure remains free lung sounds of a gallop dry skin,
 of side effects 5. Closely rhythm, eupnea with
from the monitor for tachycardia, absence of
medications symptoms of and fine pulmonary
used to heart failure crackles in crackles.
achieve and decreased lung bases can  Patient also
adequate cardiac output, indicate onset remains free
cardiac output including of heart of side effects
 Patients diminished failure. If from the
explain quality of patient medications
actions and peripheral develops used to
precautions to pulses, cold pulmonary achieve
take for and clammy edema, there adequate
cardiac skin and will be coarse cardiac output
disease extremities, crackles on  Patient is able
increased inspiration to explain
respiratory and severe actions and
rate, presence dyspnea. precautions to
of paroxysmal 5. As these take for
nocturnal symptoms of cardiac
dyspnea or heart failure disease
orthopnea, progress,
increased cardiac output
heart rate, declines.
neck vein 6. Chest
distention, pain/discomfo
decreased rt is generally
level of suggestive of
consciousness, an inadequate
and presence blood supply
of edema. to the heart,
6. Note chest which can
pain. Identify compromise
location, cardiac output.
radiation, Patients with
severity, heart failure
 quality, can continue
duration, to have chest
associated pain with
manifestations angina or can
such as reinfarct.
nausea, and 7. These actions
precipitating can increase
and relieving oxygen
factors. delivery to the
7. If chest pain is coronary
present, have arteries and
a patient lie improve
down, monitor patient
cardiac prognosis.
rhythm, give 8. Atrial
oxygen, run a fibrillation is
strip, medicate common in
for pain, and heart failure.
notify the 9. Patient may be
physician receiving
8. Place on cardiac
cardiac glycosides and
monitor; the potential
monitor for for toxicity is
dysrhythmias, greater with
especially hypokalemia;
atrial hypokalemia
fibrillation is common in
9. Examine heart patients
laboratory because of
data, diuretic use.
especially 10. Routine blood
arterial blood work can
gases and provide
electrolytes, insight into
 including the etiology of
potassium heart failure
10. Monitor and extent of
laboratory test decompensati
such as on. A low
complete serum sodium
blood count, level often is
sodium level, observed with
and serum advanced
creatinine. heart failure
11. Administer and can be a
medications as poor
prescribed, prognostic
noting side sign. Serum
effects and creatinine
toxicity levels will
12. Review results elevate in
of EKG and patients with
chest Xray severe heart
failure
because of
decreased
perfusion to
the kidneys.
Creatinine
may also
elevate
because of
ACE
inhibitors.
11. Depending on
etiological
factors,
common
medications
 include
digitalis
therapy,
diuretics,
vasodilator
therapy, anti
dysrhythmics,
angiotensin-
converting
enzyme
inhibitors, and
inotropic
agents.
12. 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
cardiomyopat
hy or large
pericardial
effusion.