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Care planning decreased cardiac output

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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

BostonFNP, APRN

Specializes in Adult Internal Medicine. Has 10 years experience.

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!

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!

PatMac10,RN, RN

Specializes in Nursing Education, CVICU, Float Pool. Has 8 years experience.

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?

That's my issue haha. I havent found a sound number for a normal EF. I know that

BostonFNP, APRN

Specializes in Adult Internal Medicine. Has 10 years experience.

For your outcomes, what would want see his BP be? His peripheral pulses? His lung sounds? Cap refill? His HR and rhythm?

PatMac10,RN, RN

Specializes in Nursing Education, CVICU, Float Pool. Has 8 years experience.

That's my issue haha. I havent found a sound number for a normal EF. I know that

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.

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

PatMac10,RN, RN

Specializes in Nursing Education, CVICU, Float Pool. Has 8 years experience.

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

Is fluid volume (deficit or overload) one of your Dx?

Edited by PatMac10,RN

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!!!!

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.

Oops- didnt see the info about "young man." Maybe it could improve in 2 days then if its acute.... But he's got all that other stuff and ischemia for 3+ years so makes it sound like its chronic.... Maybe still possible.... I would agree with the you and the others- focus interventions on increase CO, stabilize MAP, and the EF would reflect that when another echo is done.

BostonFNP, APRN

Specializes in Adult Internal Medicine. Has 10 years experience.

I haven't used nursing diagnosis in a bit of time so others may know more than I.

I don't think and EF improvement is an appropriate expected outcome. How are you going to evaluate it?

Instead think of outcomes you can assess that indicate improved cardiac function: blood pressure, heart rate, tissue perfusion, lung sounds.

PatMac10,RN, RN

Specializes in Nursing Education, CVICU, Float Pool. Has 8 years experience.

I haven't used nursing diagnosis in a bit of time so others may know more than I.

I don't think and EF improvement is an appropriate expected outcome. How are you going to evaluate it?

Instead think of outcomes you can assess that indicate improved cardiac function: blood pressure, heart rate, tissue perfusion, lung sounds.

Very good advice.

I haven't used nursing diagnosis in a bit of time so others may know more than I.

I don't think and EF improvement is an appropriate expected outcome. How are you going to evaluate it?

Instead think of outcomes you can assess that indicate improved cardiac function: blood pressure, heart rate, tissue perfusion, lung sounds.

I agree :-) you can't assess/ evaluate ejection fraction unless the MD orders another imaging test.

Oh, I just noticed my phone changed "fraction" to "fracture" in my first post. Haha oops-- gotta love that autocorrect!

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[/sounds good to me.....u know ur stuff]

Sent from my SGH-T989 using allnurses.com

Thanks again everyone. Yes he is CHF. He has had multiple stents placed and his diabetes doesnt make things better. I want to do BP, pulse etc but there are all WNL during my assessment. When he initially came in he was defiantly showing some s/s that I could have worked with but by the time I came to work with him he was stable with the meds. I wish I could do impaired gas exchange or another but my instructor thinks his priority is decreased CO so I have to process this one. I think i will have to take EF off because I do not have another order for the EF. I did however make that a NI: Consult with MD on ordering subsequent imaging test...

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

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????? (how does this patient have a normal echo if the EF is 28%) 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 diminish throughout. O2 sat 96% on 2L n/c

He had an AICD placed the day prior to my shift. (why did they place the AICD?)

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

His BP is not bad(why does it not appear bad...Could the heart still be working really hard?138/80 seems slightly high to me if you are trying to get the heart to work less hard) he has no peripheral pulses but that is more r/t neuropathy I think...(why would damage to the nerves cause the pulses to be absent/weak? could there be disease of the arteries of his legs like his heart? could it be that the heart is too weak to pump blood that far away from the heart?)

According to the Cleveland clinic......

Ejection fraction is a test that determines how well your heart pumps with each beat.

Left ventricular ejection fraction (LVEF) is the measurement of how much blood is being pumped out of the left ventricle of the heart (the main pumping chamber) with each contraction.

Right ventricular ejection fraction (RVEF) is the measurement of how much blood is being pumped out of the right side of the heart to the lungs for oxygen.

In most cases, the term “ejection fraction” refers to left ventricular ejection fraction..

[TABLE=class: dataTable]

[TR]

[TH]Ejection Fraction Measurement[/TH]

[TH]What it Means[/TH]

[/TR]

[TR=class: even]

[TD]55-70%[/TD]

[TD]Normal[/TD]

[/TR]

[TR=class: odd]

[TD]40-55%[/TD]

[TD]Below Normal[/TD]

[/TR]

[TR=class: even]

[TD]Less than 40%[/TD]

[TD]May confirm diagnosis of heart failure[/TD]

[/TR]

[TR=class: odd]

[TD]

[TD]Patient may be at risk of life-threatening irregular heartbeats[/TD]

[/TR]

[/TABLE]

What do the numbers mean?

Ejection fraction is usually expressed as a percentage. A normal heart pumps a little more than half the heart’s blood volume with each beat.

A normal LVEF ranges from 55-70%. A LVEF of 65, for example, means that 65% of the total amount of blood in the left ventricle is pumped out with each heartbeat. The LVEF may be lower when the heart muscle has become damaged due to a heart attack, heart muscle disease (cardiomyopathy), or other causes.

An EF of less than 40% may confirm a diagnosis of heart failure. Someone with diastolic failure can have a normal EF.

An EF of less than 35% increases the risk of life- threatening irregular heartbeats that can cause sudden cardiac arrest (loss of heart function) and sudden cardiac death. An implantable cardioverter defibrillator (ICD) may be recommended for these patients.

Your EF can go up and down, based on your heart condition and the therapies that have been prescribed.

Resource: Ejection Fraction Heart Failure Measurement, Heart.org

Ok.....you can have evidence of decreased cardiac output without measuring the EF every day. What would you assess everyday to know if the patient is .......here is another excellent resource for what to look for.....Treatment: How is heart failure treated?

You also mentioned

know that which is not true....they start looking to put people on the transplant list when the patient no longer responds to treatment and has an EF much lower than 40%. AN EF of 25% and less is common.

I find having a good care plan book makes doing these care plans amazingly easier. What care plan book do you have?

NANDA I describes decreased cardiac output as.......Inadequate volume of blood pumped by the heart per minute to meet metabolic demands of the body with the

Defining Characteristics......

Altered Heart Rate/Rhythm: Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia

Altered Preload: Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain

Altered Afterload: Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings

Altered Contractility: Crackles; cough; decreased ejection fraction; decreased left ventricular stroke work index (LVSWI); decreased stroke volume index (SVI); decreased cardiac index; decreased cardiac output; orthopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds

Behavioral/Emotional: Anxiety; restlessness...or lethargy

Related Factors (r/t)

Altered heart rate; altered heart rhythm; altered stroke volume: altered preload, altered afterload, altered contractility

^^^^I have highlighted the physical assessment/symptoms that might reflect a decreased cardiac output. How would these be measured? daily weights? I/O? Fluid restriction? administer meds as ordered?

My friend GrnTea says it best.....

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."

So your patient has decreased cardiac output R/T _________(CAD, ischemic cardiomyopathy) AMB (AEB)_____what?(ejection fraction of 28%, dyspnea, orthopnea, c/o “dizzy and tired when I walk”, lethargic answers questions slowly, skin: pale for ethnicity,Upper and lower extremities weak, weak peripheral and femoral pulses, chest pain, diminished lung sounds)

I have the EO stated as Patient will have an improved ejection fraction within 2 days

So how woiuld you measure this? How would your patient improve if his EF was improved? Less dyspnea? improved color? less edema? decrease in weight? less fatigue weakness?

So you will weight your patient daily and the will have a decrease in weight by (whatever number) 0.5 lb daily. If they can't walk 2 feet without severe dyspnea they will be able to walk 2 and 1/2 feet (after meds adjustment, diuresis, AICD, cardiac rehab).

Depending on the patient EF can be improved upon with meds

Administer Coreg, nitrate, rouvastatin ,Lasix, spironolactone, Norvasc, Lisinopril, Spironolactone as scheduled
. If you decrease the pre-load/after-load (you have the heart work less hard and more efficiently.....) it works better.

I wish I could really emphasize getting a care plan book make your life so much easier as a student. I use Ackley: Nursing Diagnosis Handbook, 10th Edition and Gulanick: Nursing Care Plans, 7th Edition

Check out these threads....

https://allnurses.com/nursing-student-assistance/need-help-w-676574.html

https://allnurses.com/nursing-student-assistance/1st-semester-nursing-826797.html

https://allnurses.com/nursing-student-assistance/whats-difference-between-384282.html

Edited by Esme12

HI!

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

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.