Nursing Dx

Desired Outcomes/Evaluation
Criteria—Client Will:
• Display hemodynamic stability (e.g., blood pressure, cardiac output, renal perfusion/urinary output, peripheral pulses).
• Report/demonstrate decreased episodes of dyspnea, angina, and dysrhythmias.
• Demonstrate an increase in activity tolerance.
• Verbalize knowledge of the disease process, individual risk factors, and treatment plan.
• Participate in activities that reduce the workload of the heart (e.g., stress management or therapeutic medication regimen program, weight reduction, balanced activity/rest plan, proper use of supplemental oxygen, cessation of smoking).
• Identify signs of cardiac decompensation, alter activities, and seek help appropriately.

Actions/Interventions
NURSING PRIORITY NO. 1. To identify causative/contributing factors:
• Review clients at risk as noted in Related Factors. Note: Individuals with brainstem trauma, spinal cord injuries at T7 or above, may be at risk for altered cardiac output due to an uninhibited sympathetic response. (Refer to ND risk for Autonomic Dysreflexia.)
• Evaluate medication regimen; note drug use/abuse.
• Assess potential for/type of developing shock states: hematogenic, bacteremic, cardiogenic, vasogenic, and psychogenic.
• Review laboratory data (e.g., complete blood cell—CBC—count, electrolytes, ABGs, blood urea nitrogen/creatinine—BUN/Cr—cardiac enzymes, and cultures, such as blood/ wound/secretions).
NURSING PRIORITY NO. 2. To assess degree of debilitation:
• Determine baseline vital signs/hemodynamic parameters including peripheral pulses. (Provides opportunities to track changes.)
• Review signs of impending failure/shock, noting vital signs, invasive hemodynamic parameters, breath sounds, heart tones, and urinary output. Note presence of pulsus paradoxus, reflecting cardiac tamponade.
• Review diagnostic studies (e.g., pharmacological stress testing, ECG, scans, echocardiogram, heart catheterization).
• Note response to activity/procedures and time required to return to baseline vital signs.
NURSING PRIORITY NO. 3. To minimize/correct causative factors, maximize cardiac output:

ACUTE PHASE
• Position with HOB flat or keep trunk horizontal while raising legs 20 to 30 degrees in shock situation (contraindicated in congestive state, in which semi-Fowler’s position is preferred).
• Monitor vital signs frequently to note response to activities.
• Perform periodic hemodynamic measurements as indicated (e.g., arterial, CVP, pulmonary, and left atrial pressures; cardiac output).
• Monitor cardiac rhythm continuously to note effectiveness of medications and/or devices (e.g., implanted pacemaker/ defibrillator).
• Administer blood/fluid replacement, antibiotics, diuretics, inotropic drugs, antidysrhythmics, steroids, vasopressors, and/or dilators as indicated. Evaluate response to determine therapeutic, adverse, or toxic effects of therapy.
• Restrict or administer fluids (IV/PO) as indicated. Provide adequate fluid/free water, depending on client needs. Assess hourly or periodic urinary output, noting total fluid balance to allow for timely alterations in therapeutic regimen.
• Monitor rate of IV drugs closely, using infusion pumps as appropriate to prevent bolus/overdose.
• Administer supplemental oxygen as indicated to increase oxygen available to tissues.
• Promote adequate rest by decreasing stimuli, providing quiet environment. Schedule activities and assessments to maximize sleep periods.
• Assist with or perform self-care activities for client.
• Avoid the use of restraints whenever possible if client is confused. (May increase agitation and increase the cardiac workload.)
• Use sedation and analgesics as indicated with caution to achieve desired effect without compromising hemodynamic readings.
• Maintain patency of invasive intravascular monitoring and infusion lines. Tape connections to prevent air embolus and/ or exsanguination.
• Maintain aseptic technique during invasive procedures. Provide site care as indicated.
• Provide antipyretics/fever control actions as indicated.
• Weigh daily.
• Avoid activities, such as isometric exercises, rectal stimulation, vomiting, spasmodic coughing, which may stimulate a Valsalva response. Administer stool softener as indicated.
• Encourage client to breathe deeply in/out during activities that increase risk for Valsalva effect.
• Alter environment/bed linens to maintain body temperature in near-normal range. Provide psychological support. Maintain calm attitude but admit concerns if questioned by the client. Honesty can be reassuring when so much activity and “worry” are apparent to the client.
• Provide information about testing procedures and client participation.
• Assist with special procedures as indicated (e.g., invasive line placement, intra-aortic—IA—balloon insertion, pericardiocentesis, cardioversion, pacemaker insertion).
• Explain dietary/fluid restrictions.
• Refer to ND ineffective Tissue Perfusion.
NURSING PRIORITY NO. 4. To promote venous return:
POSTACUTE/CHRONIC PHASE
• Provide for adequate rest, positioning client for maximum comfort. Administer analgesics as appropriate.
• Encourage relaxation techniques to reduce anxiety.
• Elevate legs when in sitting position; apply abdominal binder if indicated; use tilt table as needed to prevent orthostatic hypotension.
• Give skin care, provide sheepskin or air/water/gel/foam mattress, and assist with frequent position changes to avoid the development of pressure sores.
• Elevate edematous extremities and avoid restrictive clothing. When support hose are used, be sure they are individually fitted and appropriately applied.
• Increase activity levels as permitted by individual condition.
NURSING PRIORITY NO. 5. To maintain adequate nutrition and fluid balance:
• Provide for diet restrictions (e.g., low-sodium, bland, soft, low-calorie/residue/fat diet, with frequent small feedings as indicated).
• Note reports of anorexia/nausea and withhold oral intake as indicated.
• Provide fluids as indicated (may have some restrictions; may need to consider electrolyte replacement/supplementation to minimize dysrhythmias).
• Monitor intake/output and calculate 24-hour fluid balance.
NURSING PRIORITY NO. 6. To promote wellness (Teaching/ Discharge Considerations):
• Note individual risk factors present (e.g., smoking, stress, obesity) and specify interventions for reduction of identified factors.
• Review specifics of drug regimen, diet, exercise/activity plan.
• Discuss significant signs/symptoms that need to be reported to healthcare provider (e.g., muscle cramps, headaches, dizzimineral loss, especially potassium.
• Review “danger” signs requiring immediate physician notification (e.g., unrelieved or increased chest pain, dyspnea, edema).
• Encourage changing positions slowly, dangling legs before standing to reduce risk for orthostatic hypotension.
• Give information about positive signs of improvement, such as decreased edema, improved vital signs/circulation to provide encouragement.
• Teach home monitoring of weight, pulse, and/or blood pressure as appropriate to detect change and allow for timely intervention.
• Promote visits from family/SO(s) who provide positive input.
• Encourage relaxing environment, using relaxation techniques, massage therapy, soothing music, quiet activities.
• Instruct in stress management techniques as indicated, including appropriate exercise program.
• Identify resources for weight reduction, cessation of smoking, and so forth to provide support for change.
• Refer to NDs Activity Intolerance; deficient Diversional Activity; ineffective Coping, compromised family Coping; Sexual Dysfunction; acute or chronic Pain; imbalanced Nutrition; deficient or excess Fluid Volume, as indicated.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Baseline and subsequent findings and individual hemodynamic parameters, heart and breath sounds, ECG pattern, presence/strength of peripheral pulses, skin/tissue status, renal output, and mentation.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s responses to interventions/teaching and actions performed.
• Status and disposition at discharge.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Discharge considerations and who will be responsible for carrying out individual actions.

• Long-term needs.
• Specific referrals made.