Care planning decreased cardiac output

allnurses Guide · Apr 15, 2013

I still don't understand how assessing ejection fraction is a nursing assessment or intervention.

nurseprnRN, BSN, RN · Apr 15, 2013

Assess, monitor evaluate are definitely nursing intervention along with carrying out doctors orders (collaborative care)
Also, we are taught that these things can only be done by an RN

Just because nurses are the ones to do an assessment or a monitoring task does not make it a nursing intervention. Believe it or not. A nursing intervention is something nursing does to effect a change. If you observe, monitor, and assess an episode of child abuse, say, have you done anything? Or do you do something about it, do you intervene?

Likewise, again, nurses do implement parts of the medical plan of care (not, say, any PT, dietary, lab, or radiology parts). This does not make these actions parts of the nursing plan of care; they are all parts of the medical plan of care.

I stand by my assertion that as an independent, autonomous, and yes, collaborative profession we have our own body of knowledge and scientific basis for actions which are not subject to direction by the physician and are independent of physician directions provided for implementing the medical plan of care.

I think students would progress further in their understanding of what it means to think like a nurse if they could be more fully informed about the difference, wrap their heads around it, and learn how to move beyond the medical plan of care in their concept of nursing.

Oh, and if you have the bedside technology for it, sure you can estimate EF and act on it-- usually by implementing some prescription from the medical plan of care.

PatMac10,RN, RN · Apr 15, 2013

I still don't understand how assessing ejection fraction is a nursing assessment or intervention.

This particular Dx is a confusing one. The best I could think to validate it is if the OP is using it as "double check" to assess the patients progress, internally, every so often.

It could sort of be applied the same way assessing/checking a patients serum Valproic acid levels before administering Divaloprex/Depakote etc....

That particular intervention isn't the best choice, as the OP had acknowledged, and it would be easier to "internally" assess progress via MAP, CO, SV, BP, HR/rhythm, cap refill measurements than having to order a EF x amount of times. Plus not having to order repeated or unnecessary tests will promote cost-effective care for the student and patient.

MendedHeart · Apr 15, 2013

Thats how we were taught..** shrugs**

My program combines all...nursing and collaborative care in care planning

nurseprnRN, BSN, RN · Apr 16, 2013

"Collaborative care" is not shorthand for "nursing diagnosis isn't something we need to do independently." Collaboration is necessary in most areas of patient care, for all disciplines. But there is no medical collaboration in nursing diagnosis at its most basic. Physicians aren't taught nursing and do not evaluate nursing practice per se (although of course they can comment on whether the parts of the medical plan of care delegated to nursing were done as prescribed).

Esme12, ASN, BSN, RN · Apr 16, 2013

Here is a partial list of nursing interventions for decreased cardiac output.............Ackley: Nursing Diagnosis Handbook, 10th Edition

Nursing Interventions and Rationales
Recognize primary characteristics of decreased cardiac output as fatigue, dyspnea, edema, orthopnea, paroxysmal nocturnal dyspnea, and increased central venous pressure. Recognize secondary characteristics of decreased cardiac output as weight gain, hepatomegaly, jugular venous distention, palpitations, lung crackles, oliguria, coughing, clammy skin, and skin color changes. EBN: A nursing study to validate characteristics of the nursing diagnosis decreased cardiac output in a clinical environment identified and categorized related client characteristics that were present as primary or secondary (Martins, Alita, & Rabelo, 2010).
Monitor and report presence and degree of symptoms including dyspnea at rest or with reduced exercise capacity, orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough, distended abdomen, fatigue, or weakness. Monitor and report signs including jugular vein distention, S3 gallop, rales, positive hepatojugular reflux, ascites, laterally displaced or pronounced PMI, heart murmurs, narrow pulse pressure, cool extremities, tachycardia with pulsus alternans, and irregular heartbeat. EB: These are symptoms and signs consistent with heart failure (HF) and decreased cardiac output (Jessup et al, 2009). In a study of primary care clients, breathlessness during exercise, limitations in physical activity, and orthopnea were the three most significant symptoms most often associated with HF (Devroey & Van Casteren, 2011).
Monitor orthostatic blood pressures and daily weights. EB: These interventions assess for fluid volume status (Jessup et al, 2009). EB: The extent of volume overload is key to deciding on appropriate treatment for HF (Lindenfeld et al, 2010).
Recognize that decreased cardiac output that can occur in a number of non-cardiac disorders such as septic shock and hypovolemia. Expect variation in orders for differential diagnoses related to the etiology of decreased cardiac output, as orders will be distinct to address primary cause of altered cardiac output. EB: A study of left ventricular function in patients with septic shock identified that 60% developed reversible left ventricular dysfunction that could successfully be hemodynamically supported with IV vasoactive medications (Vieillard-Baron et al, 2008). Obtain a thorough history. EB: It is important to assess for behaviors that might accelerate the progression of HF symptoms such as high sodium diet, excess fluid intake, or missed medication doses (Jessup et al, 2009).
Administer oxygen as needed per physician’s order. Supplemental oxygen increases oxygen availability to the myocardium. EB: Clinical practice guidelines cite that oxygen should be administered to relieve symptoms related to hypoxemia. Supplemental oxygen at night or for exercise is not recommended unless there is concurrent pulmonary disease. Resting hypoxia or oxygen desaturation may indicate fluid overload or concurrent pulmonary disease (Jessup et al, 2009).
Monitor pulse oximetry regularly, using a forehead sensor if needed. CEB: In a study that compared oxygen saturation values of arterial blood gases to various sensors, it was found that the forehead sensor was significantly better than the digit sensor for accuracy in clients with low cardiac output, while being easy to use and not interfering with client care (Fernandez et al, 2007).
Place client in semi-Fowler’s or high Fowler’s position with legs down or in a position of comfort. Elevating the head of the bed and legs in down position may decrease the work of breathing and may also decrease venous return and preload.
During acute events, ensure client remains on short-term bed rest or maintains activity level that does not compromise cardiac output. In severe HF, restriction of activity reduces the workload of the heart (Fauci et al, 2008).
Provide a restful environment by minimizing controllable stressors and unnecessary disturbances. Schedule rest periods after meals and activities. Rest helps lower arterial pressure and reduce the workload of the myocardium by diminishing the requirements for cardiac output (Fauci et al, 2008).
Apply graduated compression stockings or intermittent sequential pneumatic compression (ISPC) leg sleeves as ordered. Ensure proper fit by measuring accurately. Remove stocking at least twice a day, then reapply. Assess the condition of the extremities frequently. Graduated compression stockings may be contraindicated in clients with peripheral arterial disease (Kahn et al, 2012). EB: A study that assessed effects of ISPC on healthy adults found that there were significant increases in cardiac output, stroke volume, and ejection fraction due to increased preload and decreased afterload (Bickel et al, 2011); EBN: A study that assessed use of knee-length graduated compression stockings found they are as effective as thigh-length graduated compression stockings. They are more comfortable for clients, are easier for staff and clients to use, pose less risk of injury to clients, and are less expensive as recommended in this study (Hilleren-Listerud, 2009). EB: Graduated compression stockings, alone or used in conjunction with other prevention modalities, help promote venous return and reduce the risk of deep vein thrombosis in hospitalized clients (Sachdeva et al, 2010).
Check blood pressure, pulse, and condition before administering cardiac medications such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), digoxin, and beta-blockers such as carvedilol. Notify physician if heart rate or blood pressure is low before holding medications. It is important that the nurse evaluate how well the client is tolerating current medications before administering cardiac medications; do not hold medications without physician input. The physician may decide to have medications administered even though the blood pressure or pulse rate has lowered.
Observe for and report chest pain or discomfort; note location, radiation, severity, quality, duration, associated manifestations such as nausea, indigestion, and diaphoresis; also note precipitating and relieving factors. Chest pain/discomfort may indicate an inadequate blood supply to the heart, which can further compromise cardiac output. EB: Clients with decreased cardiac output may present with myocardial ischemia. Those with myocardial ischemia may present with decreased cardiac output and HF (Jessup et al, 2009; Lindenfeld et al, 2010).
If chest pain is present, refer to the interventions in Risk for decreased Cardiac tissue perfusion care plan.
Recognize the effect of sleep disordered breathing in HF. EB & CEB: A study assessing effects of OSA physiology on left sided cardiac function found that the increase in negative intrathoracic pressure found in OSA led to a decrease in left ventricular systolic performance (Orban et al, 2008). A study that assessed effectiveness of nasal cannula oxygen supplement for nocturnal obstructive sleep apnea found that 75% of HF clients had sleep apnea, and those who exhibited central sleep apnea had significantly reduced episodes when wearing nasal oxygen during sleep (Sakakibara et al, 2005). Sleep-disordered breathing, including obstructive sleep apnea and Cheyne-Stokes with central sleep apnea, are common organic sleep disorders in clients with chronic HF and are a poor prognostic sign associated with higher mortality (Brostrom et al, 2004).
Closely monitor fluid intake, including intravenous lines. Maintain fluid restriction if ordered. In clients with decreased cardiac output, poorly functioning ventricles may not tolerate increased fluid volumes.
Monitor intake and output. If client is acutely ill, measure hourly urine output and note decreases in output. EB: Clinical practice guidelines cite that monitoring I&Os is useful for monitoring effects of diuretic therapy (Jessup et al, 2009). Decreased cardiac output results in decreased perfusion of the kidneys, with a resulting decrease in urine output.
Note results of electrocardiography and chest radiography. CEB: Clinical practice guidelines suggest that chest radiography and electrocardiogram are recommended in the initial assessment of HF (Jessup et al, 2009).
Note results of diagnostic imaging studies such as echocardiogram, radionuclide imaging, or dobutamine-stress echocardiography. EB: Clinical practice guidelines state that the echocardiogram is a key test in the assessment of HF (Jessup et al, 2009).
Watch laboratory data closely, especially arterial blood gases, CBC, electrolytes including sodium, potassium and magnesium, BUN, creatinine, digoxin level, and B-type natriuretic peptide (BNP assay). Routine blood work can provide insight into the etiology of HF and extent of decompensation. EB: Clinical practice guidelines recommend that BNP or NTpro-BNP assay should be measured in clients when the cause of HF is not known (Jessup et al, 2009). A study assessed hyponatremia as a prognostic indicator in clients with preserved left ventricular function and found that hyponatremia at first hospitalization is a powerful predictor of long-term mortality in this group (Rusinaru et al, 2009). Serum creatinine levels will elevate in clients with severe HF because of decreased perfusion to the kidneys. Client may be receiving cardiac glycosides, and the potential for toxicity is greater with hypokalemia; hypokalemia is common in heart clients because of diuretic use (Fauci et al, 2008).
Gradually increase activity when client’s condition is stabilized by encouraging slower paced activities or shorter periods of activity with frequent rest periods following exercise prescription; observe for symptoms of intolerance. Take blood pressure and pulse before and after activity and note changes. Activity of the cardiac client should be closely monitored. See Activity Intolerance.
Serve small, frequent, sodium-restricted, low saturated fat meals. Sodium-restricted diets help decrease fluid volume excess. Low saturated fat diets help decrease atherosclerosis, which causes coronary artery disease. Clients with cardiac disease tolerate smaller meals better because they require less cardiac output to digest. EB: A study that compared cardiac event-free survival between clients who ingested more or less than 3 grams of dietary sodium daily found that those who were NYHA class III or IV clients benefited the most from dietary intake less than 3 grams daily (Lennie et al, 2011); EB: A study that compared HF symptoms with dietary sodium intake found that those with sodium intakes greater than 3 grams per day had more HF symptoms (Son et al, 2011). Emphasis on use of unsaturated fats and less use of saturated fats in the diet is recommended to reduce cardiovascular risk. Polyunsaturates are beneficial to vascular endothelial function, while saturated fats impair vascular endothelial function (Hall et al, 2009; Willett et al, 2011).
Serve only small amounts of coffee or caffeine-containing beverages if requested (no more than four cups per 24 hours) if no resulting dysrhythmia. CEB: A review of studies on caffeine and cardiac arrhythmias concluded that moderate caffeine consumption does not increase the frequency or severity of cardiac arrhythmias (Hogan, Hornick, & Bouchoux, 2002; Myers & Harris, 1990; Schneider, 1987).
Monitor bowel function. Provide stool softeners as ordered. Caution client not to strain when defecating. Decreased activity, pain medication, and diuretics can cause constipation. The Valsalva maneuver which can be elicited by straining during defecation, cough, lifting self onto the bedpan, or lifting self in bed can be harmful (Moser et al, 2008).
Have clients use a commode or urinal for toileting and avoid use of a bedpan. Getting out of bed to use a commode or urinal does not stress the heart any more than staying in bed to toilet. In addition, getting the client out of bed minimizes complications of immobility and is often preferred by the client (Winslow, 1992).
Weigh client at same time daily (after voiding). EB: Clinical practice guidelines state that weighing at the same time daily is useful to assess effects of diuretic therapy (Jessup et al, 2009). Use the same scale if possible when weighing clients. Daily weight is also a good indicator of fluid balance. Increased weight and severity of symptoms can signal decreased cardiac function with retention of fluids.
Provide influenza and pneumococcal vaccines prior to discharge for those who have yet to receive them. EB: Clinical practice guidelines and a Scientific Statement cite that HF hospitalizations are more likely during influenza and winter season, and that having the immunization minimizes that risk (Lindenfeld et al, 2010; Riegel et al, 2009).
Assess for presence of anxiety and refer for treatment if present. See Nursing Interventions and Rationales for Anxiety to facilitate reduction of anxiety in clients and family. EB: A clinical practice guideline recommends that non-pharmacological techniques for stress reduction are a useful adjunct for reduction of anxiety in HF clients (Lindenfeld et al, 2010). A study that assessed the relationship between anxiety and incidence of death, emergency department visits, or hospitalizations found that those with higher anxiety had significantly worse outcomes than those with lower anxiety (De Jong et al, 2011).
Refer for treatment when depression is present. EBN: A study on combined depression and level of perceived social support found that depressive symptoms were an independent predictor of increased morbidity and mortality, and those with lower perceived social support had 2.1 times higher risk of events than nondepressed clients with high perceived social support (Chung et al, 2011). A qualitative study that described experiences of clients living with depressive symptoms found that negative thinking was present in all participants, reinforcing depressed mood; multiple stressors worsened depressive symptoms; and depressive symptoms were reduced by finding activities from which to distract (Dekker et al, 2009). A study that assessed health-related quality of life found that baseline depression along with perceived control were strongest predictors of physical symptom status (Heo et al, 2008).
Refer to a cardiac rehabilitation program for education and monitored exercise. EB & CEB: Clients with HF should be referred for exercise training when deemed safe, to promote exercise expectations, understanding, and adherence (Lindenfeld et al, 2010). A systematic review of outcomes of exercise based interventions in clients with systolic HF found that hospitalizations and those for systolic HF were reduced for clients in an exercise program and quality of life was improved (Davies et al, 2010). In a study to assess effects of exercise in HF clients, exercise tolerance and left ventricular ejection fraction increased with exercise training (Alves et al, 2012).
Refer to HF program for education, evaluation, and guided support to increase activity and rebuild quality of life. CEB: A study assessing the 6-month outcomes of a nurse practitioner-coordinated HF center found that readmissions, length of stay, and cost per case were all significantly reduced, while quality of life was significantly improved (Crowther et al,

2002).

nurseprnRN, BSN, RN · Apr 16, 2013

Love it. If you read closely, you see how monitoring gets considered and applied, not just done.

R. Obias Jr., R.N. · Apr 16, 2013

ejection fraction more often requires long term medication, as in taking maintenance meds, due to pre existing condition indicated in pt's history, your expected EO for this is to educate patient on his condition, advise on proper taking of maintenance meds, ejection fraction can be considered as a symptom here related to his other pre existing conditions, when patient was admitted, he probably was having a heart or anxiety attack.....

allie86 · Apr 20, 2013

Oh thank you so much. This was very informative. I also use Ackley! I like it but I just was confused on how to use EF. I winded up changing it after the input from here! Thanks again!

allie86 · Apr 20, 2013

Here is a partial list of nursing interventions for decreased cardiac output.............Ackley: Nursing Diagnosis Handbook, 10th Edition
2002).

Thank you I use Ackley too. I got some good NI from here but had to change my EO. I just took out the EF and used DOE and c/o fatigue... We worked on improving that in my NI. Thanks again

allie86 · Apr 20, 2013

ejection fraction more often requires long term medication, as in taking maintenance meds, due to pre existing condition indicated in pt's history, your expected EO for this is to educate patient on his condition, advise on proper taking of maintenance meds, ejection fraction can be considered as a symptom here related to his other pre existing conditions, when patient was admitted, he probably was having a heart or anxiety attack.....

Thank you. Yes that I what I did instead. Having EF as a AMB was too difficult. IN my program anything and everything in the AMB has to be addressed and made into an EO. I just didnt see how EF could be improved in a short term goal so I replaced it with other evidence.

allie86 · Apr 20, 2013

I hear what your saying. However, our program tells us to do it this way. Trust if it was up to me I would do it much different. We ALWAYS have to assess for our EO first and monitor teach and treat. Thats what they want and since I am the student and not the instructor....I must follow! I know many nursing programs are different and these instructors all have their preferred ways. I definitely use my NANADA list. They only allow us to use a select few and in my case here, I was told to use decreased cardiac output. On the contrary I think I really do think like a nurse I have always thought critically. In class its a different method. Not so critically but how they want us to learn. Im ok with that. I dont mind learning and I thank you for your input too. Just want you to know that this way is one of many that some school teach...whether its good or not.

These "interventions" are not interventions. Assessment and monitoring are not interventions; implementing parts of the medical plan of care are not nursing interventions. Interventions make a difference in something; monitoring and assessment (including reviewing diagnostic imaging) are not actions that change a thing.

You have almost nothing here about nursing assessment.

I just wrote a fairly detailed critique of care plan for someone with a patient who has CHF. You might want to look at that. Briefly, I think you are thinking about medical diagnosis, interventions, and assessments. You need to look to your NANDA-I 2012-2014 to identify the defining characteristics allowing you to make nursing diagnoses; once you have done that, the way to developing a nursing plan of care based on nursing assessment and interventions will become clearer to you. It's $29 at Amazon, free two-day delivery for students; $24 on your Kindle. Get it stat.

This exercise is to help you learn to think like a nurse. Not there yet.