Care planning decreased cardiac output

  1. 0
    HI! I was hoping someone could help me out with this care plan I have. I have spent hours and trolled the internet for answers to no avail! BTW I am a 2nd semester RN student!

    My patient is a young man with an ejection fracture of 28%. He came in through ED with c/o chest pains unrelieved with nitroglycerin and increased troponin and CK with elevated BP 221/87; normal echo in sinus rhythm and the following hx:

    Insulin dependent DM (uncontrolled) X 7 yrs CABG X 3 yrs ago with 6 stents
    Hypertension X yrs Amputation of left great toe X yrs ago
    Hyperlipidemia X yrs Amputation of right third toe X yrs ago
    CAD X 3yrs
    Ischemic Cardiomyopathy x yrs
    Peripheral neuropathy X yrs
    Retinopathy X yrs

    His v/s BP: 136/80; Pulse: 76 regular 2+/3, Apical pulse: 82 regular, radial pulses 2+/3 regular bilat.; femoral and pedal pulses 1+/3 weak bilaterally; lung sounds dimishined throughout. O2 sat 96% on 2L n/c

    He had an AICD placed the day prior to my shift.

    My care plan is Decreased cardiac output r/t alterations in preload, afterload and myocardial contractility 2° cardiomyopathy and cardiac ischemia x 4 yrs ago amb (as manifested (evidenced) by) dyspnea on exertion, orthopnea, c/o “dizzy and tired when I walk”, ejection fracture of 28%

    I have completed my expected outcome for the DOE, orthopnea and weakness; however my program requires us to have an EO for each amb. So for the ejection fracture i am stuck. I have the EO stated as Patient will have an improved ejection fracture within 2 days but now I am thinking this isnt possible. After reading through my books and journals it seems as though an ejection fracture seldom improves and when it does they dont know why?! And now my EO sounds more like a MD problem than a RN one.

    I have made some NI for this EO but I am not sure if they are even accurate or good. Here is what I have so far

    2a. Assess ejection fracture
    2b. Monitor lab results daily
    2c. Review results of diagnostic imaging (ECG, EKG, radionuclide) Q shift
    2d. Administer Coreg, nitrate, rouvastatin ,Lasix, spironolactone, Norvasc, Lisinopril, Spironolactone as scheduled
    2e.Consult with case manager to refer to cardiac rehabilitation program for education, evaluation. And guided support to increase activity

    Do you think I am on the right track with using EF as a EO? Or should I change it? If I change it, what else would show decreased cardiac output? His BP is not bad, he has no peripheral pulses but that is more r/t neuropathy I think... His HR is WNL and well controlled on his current medications....thanks in advance
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  3. 38 Comments so far...

  4. 0
    You have told us a lot of his medical diagnosis. What was your assessment of him? Your care plan should be based on your assessment.


    And change fracture to fraction!
  5. 0
    Thanks I will change that!!

    My assessment was the DOE, diminished lung sounds, weak peripheral and femoral pulses, chest pain, impaired vision and hearing, orthopnea

    limitations in all ROM, Upper and lower extremities weak against resistance, he has no feeling in his lower extremities or feet, obesity bmi 33, he was really lethargic answers questions slowly, skin: pale for ethnicity, as far as labs go he has increased WBC, CK (206 units) Troponin, HCT, Triglycerides, BUN, Creatnine, Hgb A1c (11.2%), decreased albumin

    The thing is I have to do decreased cardiac output but i dont feel like I have enough to do the two EO's we have to do. My other care plan for him is activity intolerance which is easier but this one has me stuck!
  6. 0
    One thing that my instructors harp on are being specific and having measurable outcomes. What parameters, exactly do you want to aim for his Ejection Fraction to be?
  7. 0
    That's my issue haha. I havent found a sound number for a normal EF. I know that <40% is when they typically start looking at transplanting. So I was just hoping his EF could increase period. As far as timeframe to increase, I was hoping two days would be enough to show even a slight increase. He just had a AICD placed he is on bed rest with cardiac meds. So I thought his plan of care could really help increase his EF. My other patient came in with an EF of 15% and increased to 28% with meds by 2 days. But then again I may be completely off base! Thanks for the reply and help!
  8. 0
    For your outcomes, what would want see his BP be? His peripheral pulses? His lung sounds? Cap refill? His HR and rhythm?
  9. 1
    Quote from allie86
    That's my issue haha. I havent found a sound number for a normal EF. I know that <40% is when they typically start looking at transplanting. So I was just hoping his EF could increase period. As far as timeframe to increase, I was hoping two days would be enough to show even a slight increase. He just had a AICD placed he is on bed rest with cardiac meds. So I thought his plan of care could really help increase his EF. My other patient came in with an EF of 15% and increased to 28% with meds by 2 days. But then again I may be completely off base! Thanks for the reply and help!
    Ok. So. According to the Cleveland clinic (reputable source) normal range is Approx 55% to 70%. So, like BostonFNP mentioned, your outcomes need to reflect things that would improve the patients EF. Like and increase in CO, increase in MAP etc.... Those things will inadvertently effect the patients EF. With the patient being a youngman I feel that 2days is more than sufficient time to allow for an increase in EF, if the tx and interventions are effective.
    Esme12 likes this.
  10. 0
    Ok thanks to both of you! I guess I better stick with this EO and just focus my NI on increasing CO, MAP which will inadvertently increase EF. Thanks
  11. 0
    Allie,

    Don't forget about stroke volume either. An increase in strike volume will increase EF.

    I feel like I didn't explain myself thoroughly for some reason. Anyway, EF will also affect CO and Map, as they would effect the EF. They all kind of play off of each other. If that makes sense.

    By seeing cap refill < or = to 3 seconds you know that the patient is becoming hemodynamically stable.

    Is fluid volume (deficit or overload) one of your Dx?
    Last edit by PatMac10,RN on Apr 12, '13
  12. 0
    I would recommend taking ejection fracture out if you stick with decreased cardiac output. This guy probably has CHF and that EF isn't going to get much better. Therefore, your research is correct with the 2 day improvement for an EF being sort of impossible. Also, someone correct me if I'm wrong, but not sure they're going to order another echo so you can tell that the EF is going to improve in 2 days. I have been on the cardiac telemetry floor this semester and in going through the records of my pts, they usually only have one in there... And I've had a couple pts there for a few weeks. I know its a care plan and not an actual intervention, but if you don't have a doctor order another EF, then that intervention couldn't be in your scope of practice--your instructor grading it might probably knows about if echoes are ordered that often or not...

    For care plans, I always focus on the ABCs (and pathophysiology) first for nursing diagnoses and EO and develop from there. For instance. He's got diminished breath sounds, dyspnea, and orthopnea.... I would focus on his breathing first for a diagnosis- diminished gas exchange, etc. It never hurts to mention what works for someone else in deciding which diagnosis to go with :-) we gotta help each other through this!

    Oh, for your NIs, you could probably mention your continuing admin of meds, the diuretic and anticoagulant administration. There's increased fluid production and eventually edema (he seems like hes in the late stages with the 28%!) when cardiac output is decreased and blood congests. Both of these would improve circulation (and breathing). Hope these suggestions help!!!!


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