Care planning decreased cardiac output

PatMac10,RN, RN · Apr 13, 2013

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.

molls4 · Apr 13, 2013

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!

iiiwideshut · Apr 13, 2013

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]
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allie86 · Apr 13, 2013

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 · Apr 13, 2013

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

nurseprnRN, BSN, RN · Apr 14, 2013

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.

PatMac10,RN, RN · Apr 14, 2013

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.

Assessment not an intervention, implementing physician orders not an nursing intervention? ( Ok the last one I kind of understand, but who else is going to implement the orders?)

If that's the case, which ice never heard that before, then I've been taught care planning wrong these past two years, and that's hard for me to believe when some of our faculty have been on advisory boards for nursing textbooks on clinical care and care-planning.

All of my books which span from a publishing range of 2009 to 2012 cute specified assessments, "monitoring", or "evaluating" as a nursing intervention.

I also googled and found nothing regarding Assessment not being a NI.

However, I am not saying your wrong, because sometimes it could be something that everyone has been misinformed by, I very highly doubt a whole nursing school faculty and their students, but who knows.

Here's a book we've used as a reference throughout nursing school.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2009). Davis's Nurses Pocket Guide. (12 ed.). Philadelphia: F.A. Davis Company.

Esme12, ASN, BSN, RN · Apr 15, 2013

I agree that the assessment and monitoring is apart of the interventions they are in my care plan book as well.

nurseprnRN, BSN, RN · Apr 15, 2013

A part, yes.

Doenges et al. is a great book. However, I think you will find upon closer inspection that they give you more suggestions on things to do for patients than just assessments and monitoring. These actions are only useful if you say what you will do if the interventions disclose information upon which you will act (and say how).

While assessment activities are things you will be doing, they can't be all you'll do. Else why bother having nurses at all? All we'd need is monitor techs to look at readouts and add them to the charts, and perhaps to report them to the physicians. No nursing judgment, no nursing actions, just ...monitoring.

PatMac10,RN, RN · Apr 15, 2013

A part, yes.
Doenges et al. is a great book. However, I think you will find upon closer inspection that they give you more suggestions on things to do for patients than just assessments and monitoring. These actions are only useful if you say what you will do if the interventions disclose information upon which you will act (and say how).
While assessment activities are things you will be doing, they can't be all you'll do. Else why bother having nurses at all? All we'd need is monitor techs to look at readouts and add them to the charts, and perhaps to report them to the physicians. No nursing judgment, no nursing actions, just ...monitoring.

Oh ok. I think i see what you were saying. I agree that assessments and monitoring shouldn't be the only Interventions. If all you ever do is assess and never implement it is futile. According to all of my resources, though, assessment and monitoring are most certainly, a nursing intervention.

nurseprnRN, BSN, RN · Apr 15, 2013

And that is why I said that this list* isn't a plan of care for nursing intervention. Now that we have gone full circle...what defining characteristics of this patient lead you to the nursing diagnosis, and what will you, the nurse, do about those defining characteristics?

*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

MendedHeart · 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