Need help for goal/interventions-decreased cardiac output

  1. 0
    I was preplanning today and my patient's blood pressure went way, way down. It was 77/49 before I left. We have to choose 3 nursing diagnoses. I chose Decreased Cardiac output due to the blood pressure. I'm lost when it comes to a goal, though. My teacher won't let us use anything like "patient's blood pressure will increase by the end of the shift." She says increase isn't measurable. It has to be specific- but I cannot expect his blood pressure to just spike into the normal range out of no where, ya know? Anyone have a good idea on what I can say? Anyone have any ideas on some interventions as well?

    BP=77/49
    HR=86
    RR=16
    SaO2=94%
    Pt is in the hospital for nausea and vomitting. Pt smokes 3 packs a day. History of COPD and lung cancer.

    My other nursing diagnoses are Impaired gas exchange r/t smoking as evidenced by COPD. Nausea r/t ?? (I don't know why he is nauseous??) aeb patient report of strong nauseous feeling (8/10)
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  4. 1
    How about any of these?

    "Pt's systolic blood pressure will be >90 by the end of the shift; Pt will have good < 3 second capillary refill to extremities; Pt will not experience s/s of low blood pressure"?

    Re: the nausea. Is it possible to do a teaching on how to avoid food/drink that would exacerbate the nausea? For example, the patient might want to avoid spicy foods, carbonated beverages, etc. I think there's a Knowledge deficit NANDA that you might use along these lines, but I don't recall the exact wording.
    Cheer4WVU likes this.
  5. 1
    http://www.emedicinehealth.com/low_b...article_em.htm - hypotension

    a low b/p by itself i would diagnose as decreased cardiac output r/t decreased contractility aeb low b/p of 77/49. however, your instructor has a valid argument. a diagnosis is made on the basis of evidence that was collected and we determine its status by what happens to that evidence as time goes on. does it improve or stay the same? your goal statements are merely written predictions of how you think things will improve. and, yes, they must be measurable. a blood pressure is measured with a blood pressure cuff. so, when you say things like "low blood pressure" and "the patient will have a normal blood pressure by noon" this cannot be measured. there are no "normal" markings on a blood pressure cuff. but if you say, "the patients blood pressure will return to 110/60 by noon," that is measurable because we can put the blood pressure cuff on the patient and take a measurement and compare it against a parameter that we set.

    decreased cardiac output r/t decreased contractility aeb low b/p of 77/49

    goal: the patient's blood pressure will return to 110/60 while on bed rest in 24 hours
    goal: by discharge the patient will demonstrate standing slowly when getting out of the bed or a chair.

    • ask the patient if he has experienced any weakness, nausea, dizziness and/or chest pain recently
    • assess the skin for pallor, sweating and clamminess
    • take lying, sitting and standing blood pressures q4h while awake and record
    • palpate the pulses in the extremities of the arms and legs q4h while awake and record
    • make sure the patient has his o2 tubing positioned correctly and that the o2 is on and running
    • assist the patient when standing and ambulating and do not leave unattended
    • encourage oral fluid intake
    • if b/p goes below 80/60 or patient complains of dizziness maintain bed rest
    • teach patient to stand slowly when getting out of the bed or a chair
    • discuss the need for assistive devices for ambulation
    • talk with the patient about the importance of adequate fluid intake
    impaired gas exchange r/t smoking as evidenced by copd
    the related factor and aeb are all wrong. there are only 2 related factors for impaired gas exchange.
    • the alveoli are so damaged by disease that the o2/co2 interchange is compromised (alveolar-capillary membrane changes)
    • the alveoli are so clogged up with exudates and secretions that the o2/co2 interchange is compromised (ventilation perfusion imbalance)
    since this patient has copd the winner is alveolar-capillary membrane changes. smoking caused the problem. he has a more specific disease as well. copd is a broad term and there are 4 respiratory diseases that fall under it. emphysema or obstructive bronchitis are more likely what he has. your "as evidenced by" part of the diagnostic statement is the data (evidence) you found that proves he has impaired gas exchange (excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane). there is no way you assessed this patient and found him to have copd. only a doctor can do that. if you look at the defining characteristics (a fancy name for signs and symptoms) on this website you will see what some of the evidence of impaired gas exchange is: impaired gas exchange. your diagnostic statement should begin as impaired gas exchange r/t alveolar-capillary membrane changes aeb [the patient's symptoms]
    nausea r/t ?? (i don't know why he is nauseous??) aeb patient report of strong nauseous feeling (8/10)
    not why he is nauseous, but what the underlying reason is for the nausea to have occurred. this is not uncommon with copders. it may be his medications. if he is having low b/ps he may also be having dizziness and dizziness leads to nausea. this hypotension he is having may be positional or it may be brought on by his coughing. the heart and lungs are so closely linked to each other that it is hard to know if they are not entwined here. nausea and heart problems often go hand in hand.
    Cheer4WVU likes this.
  6. 0
    Thank you both very, very much for your in depth answers- things are much clearer now! I actually went in and saw the patient today and the reason his blood pressure has shot down so much is because he is having some internal bleeding. They don't really know whats going on or really bleeding yet, though.

    Daytonight- thanks for the info for impaired gas exchage especially. Extremely helpful.

    I ended up saying nausea r/t GI bleeding as evidenced by patient report of nausea on a scale as 8/10.
  7. 0
    i thought maybe something like that was going on. i hope they find what is happening. i worry that it won't be good. the copd isn't helping. i saw this happen before with our frequent flyer copders. if they, god forbid, find a cancer somewhere, surgery may not be an option because of his respiratory problems. whatever depression these patients have from the copd doubles with the new diagnosis. if ever there is a reason for telling people why they shouldn't smoke. . .
  8. 0
    Low blood pressure does not automatically imply decreased cardiac output. It could also be caused by decreased systemic vascular resistance (SVR), without a decrease in cardiac output. And even if the low BP does lead to decreased CO, it doesn't necessarily follow that there's decreased contractility. The decrease in CO could be due to decrease in preload.
  9. 1
    Quote from fins
    low blood pressure does not automatically imply decreased cardiac output.
    it certainly does.

    the physiology of blood pressure consists of two main components:
    • cardiac output
      • heart rate - beats per minute
      • stroke volume - amount of blood pumped per beat
    • peripheral resistance - resistance of the arteries against the flow of blood through them
    increasing any one of the above factors increases the blood pressure and vice versa.

    when the blood pressure is abnormal, any of the above factors is involved.
    Angie O'Plasty, RN likes this.
  10. 0
    I think fins' point is that a patient can have a decreased BP and yet a preserved CO, in the setting of low SVR. In theory, low BP does not = low CO. eg. in sepsis, there's usually high CO with low BP.
  11. 0
    the physiology of blood pressure consists of two main components:
    • cardiac output
      • heart rate - beats per minute
      • stroke volume - amount of blood pumped per beat
    • peripheral resistance - resistance of the arteries against the flow of blood through them
    increasing any one of the above factors increases the blood pressure and vice versa.

    when the blood pressure is abnormal, any of the above factors is involved.[/quote]

    you're right when you say that when the blood pressure is abnormal, any of the above factors is involved.
    so, if the bp is low, it could be because the cardiac output is low. but, it could also be because the peripheral resistance is low, while the cardiac output remains normal. so you absolutely can have a low bp without a decreased cardiac output. i was specifically thinking about sepsis. as the previous poster pointed out, in the early stages of sepsis, you can have a drop in bp and yet have an increased cardiac output - the decrease in resistance being more than enough to offset the increase in co, with a net result of decreased blood pressure.

    i wasn't trying to say that low co won't cause low bp - it certainly will. i'm saying that you can have low bp without decreased co being the cause.
    Last edit by fins on Feb 15, '09 : Reason: clarification


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