NURSING CARE PLAN: DECREASED CARDIAC OUTPUT

CUES NURSING DIAGNOSIS ANALYSIS

GOALS AND OBJECTIVES

NURSING INTERVENTION RATIONALE EVALUATION

Objective: Decreased

cardiac output BP: 200/120

T:39.0 C Vomiting Lethargic

Decreased cardiac output related to malignant hypertension as manifested by low stroke volume

Hypertension (HTN) or high blood pressure is a chronic medical condition in which the systemic arterial blood

pressure is elevated. It is the opposite of hypotension. It

is classified as either primary (essential) or secondary.

About 90–95% of cases are termed "primary

hypertension", which refers to high blood pressure for

which no medical cause can be found. The remaining 5–

10% of cases (Secondary hypertension) are caused by other conditions that affect the kidneys, arteries, heart,

or endocrine system.

Persistent hypertension is one of the risk factors for

stroke, myocardial infarction, heart failure and arterial aneurysm, and is a

leading cause of

After 6 hrs of nursing interventions, the client will have no elevation in blood pressure above normal limits and will maintain blood pressure with inacceptable limits

After 5 days of nursing interventions t he client will maintain adequate cardiac output and cardiac index

afterload is not increased,

vasoconstriction does not occur,

myocardial ischemia does not occur.

Monitor BP lying, sitting, and standing, if able. Note widened pulse pressure.

. Monitor central venous pressure (CVP), if available.

Investigate reports of chest pain and angina.

General and orthostatic hypotension may occur as a result of excessive peripheral vasodilation and decreased circulating volume. Widened pulse pressure reflects compensatory increase in stroke volume and decreased SVR.

Provides more direct measure of circulating volume and cardiac function

May reflect increased myocardial oxygen demands

Effectiveness:After 8 hours of nursing intervention, was the client able to maintain blood pressure with inacceptable limitsYes_ No_ Why?_

Efficiency:Were the resources of the nurse and patient efficient and be able to maximize?Yes_ No_ Why?_

Appropriateness:Were all the interventions to the client are appropriate for her to attain the desired goal?Yes_ No_ Why?_

chronic kidney failure. Moderate elevation of

arterial blood pressure leads to shortened life

expectancy. Dietary and lifestyle changes can

improve blood pressure control and decrease the risk of associated health complications, although

drug treatment may prove necessary in patients for whom lifestyle changes

prove ineffective or insufficient.

>Assess pulse and heart rate while client is sleeping.

>Auscultate heart sounds, noting extra heart sounds and development of gallops and systolic murmurs.

>Monitor temperature, provide cool environment, limit bed linens and clothes, and administer tepid sponge baths.

and ischemia.

>Provides a more accurate assessment of tachycardia.

>Prominent S1 and murmurs are associated with forceful cardiac output of hyper metabolic state; development of S3 may warn of impending cardiac failure.

>Fever, which may exceed 104°F (40.0°C), can occur as a result of excessive hormone levels increasing diuresis and dehydration, causing increased peripheral vasodilatation,

Acceptability:Were all the interventions to the client are acceptable for her ?Yes_ No_ Why?_

Adequacy: Were the interventions adequate for her to attain the desired goal?Yes_ No_ Why?_

>Observe for signs and symptoms of severe thirst, dry mucous membranes, weak and thready pulse, poor capillary refill, decreased urinary output, and hypotension.

venous pooling, and hypotension.

>Rapid dehydration can occur, which reduces circulating volume and compromises cardiac output.