Assess mentation. ---Restlessness is noted in the early stages; severe anxiety and confusion are seen in later stages.

Assess heart rate and blood pressure.--- Sinus tachycardia and increased arterial blood pressure are seen in the early stages; BP drops as the condition deteriorates. Elderly patients have reduced response to catecholamines, thustheir response to reduced cardiac output may be blunted, with less rise in heart rate. Pulsus alternans (alternating strong-then-weak pulse) is often seen in heart failure patients. Assess skin color and temperature.----Cold, clammy skin is secondary to compensatory increase in sympathetic nervous system stimulation and low cardiac output and desaturation. Assess peripheral pulses.---Pulses are weak with reduced cardiac output. Assess fluid balance and weight gain.----Compromised regulatory mechanisms may result in fluid and sodium retention. Body weight is a more sensitive indicator of fluid or sodium

Assess fluid balance and weight gain. Compromised regulatory mechanisms may result in fluid and sodium retention. Body weight is a more sensitive indicator of fluid or sodium retention than intake and output. Assess heart sounds, noting gallops, S3, S4. S3 denotes reduced left ventricular ejection and is a classic sign of left ventricular failure. S4 occurs with reduced compliance of the left ventricle, which impairs diastolic filling. Assess lung sounds. Determine any occurrence of paroxysmal nocturnal dyspnea (PND) or orthopnea. Crackles reflect accumulation of fluid secondary to impaired left ventricular emptying. They are more evident in the dependent areas of the lung. Orthopnea is difficulty breathing when supine. PND is difficulty breathing that occurs at night. If hemodynamic monitoring is in place: Monitor central venous, right arterial pressure [RAP], pulmonary artery pressure (PAP) (systolic, diastolic, and mean), and pulmonary capillary wedge pressure (PCWP). Hemodynamic parameters provide information aiding in differentiation of decreased cardiac output secondary to fluid overload versus fluid deficit. Monitor SVO 2 continuously.

Change in oxygen saturation of mixed venous blood is one of the earliest indicators of reduced cardiac output. Perform cardiac output determination. This provides objective number to guide therapy. Monitor continuous ECG as appropriate. Monitor ECG for rate; rhythm; ectopy; and change in PR, QRS, and QT intervals. Tachycardia, bradycardia, and ectopic beats can compromise cardiac output. Elderly patients are especially sensitive to the loss of atrial kick in atrial fibrillation.

Assess response to increased activity. Physical activity increases the demands placed on the heart; fatigue and exertional dyspnea are common problems with low cardiac output states. Close monitoring of patients response serves as a guide for optimal progression of activity. Assess urine output. Determine how often the patient urinates. Oliguria can reflect decreased renal perfusion. Diuresis is expected with diuretic therapy. Assess for chest pain. This indicates an imbalance between oxygen supply and demand. Assess contributing factors so appropriate plan of care can be initiated. NURSING INTERVENTIONS RATIONALE Administer medication as prescribed, noting response and watching for side effects and toxicity. Clarify with physician parameters for withholding medications. Depending on etiological factors, common medications include digitalis therapy, diuretics, vasodilator therapy, antidysrhythmics, ACE inhibitors, and inotropic agents. Maintain optimal fluid balance. For patients with decreased preload, administer fluid challenge as prescribed, closely monitoring effects. Administration of fluid increases extracellular fluid volume to raise cardiac output

Maintain hemodynamic parameters at prescribed levels. For patients in the acute setting, close monitoring

of these parameters guides titration of fluids and medications. For patients with increased preload, restrict fluids and sodium as ordered. This decreases extracellular fluid volume Maintain adequate ventilation and perfusion, as in the following: Place patient in semi- to high-Fowlers position. This reduces preload and ventricular filling. Place in supine position. This increases venous return, promotes diuresis. Administer humidified oxygen as ordered. The failing heart may not be able to respond to increased oxygen demands. Maintain physical and emotional rest, as in the following: Restrict activity. This reduces oxygen demands. Provide quiet, relaxed environment. Emotional stress increases cardiac demands. Organize nursing and medical care. This allows rest periods. Monitor progressive activity within limits of cardiac function. Administer stool softeners as needed. Straining for a bowel movement further impairs cardiac output. Monitor sleep patterns; administer sedative. Rest is important for conserving energy. If arrhythmia occurs, determine patient response, document, and report if significant or symptomatic. Have antiarrhythmic drugs readily available. Treat arrhythmias according to medical orders or protocol and evaluate response. Both tachyarrhythmias and bradyarrhythmias can reduce cardiac output and myocardial tissue perfusion. If invasive adjunct therapies are indicated (e.g.,intraaortic balloon pump, pacemaker), maintainwithin prescribed protocol. PATIENT TEACHING RATIONALE Explain symptoms and interventions for decreased cardiac output related to etiological factors. Explain drug regimen, purpose, dose, and side effects.

Explain progressive activity schedule and signs of overexertion. Explain diet restrictions (fluid, sodium).

Intervention Assess patient respirations by observing respiratory rate and depth and use of accessory muscles Observe patient for restlessness, agitation, confusion and (late stages) lethargy Auscultate lungs for presence of normal or adventitious lung sounds Assess patient for positive hepatojugular reflex Assess for mental status changes. Weigh patient daily at same time with same clothing on same scale. Observe patient for sleep apnea Assess patient for chest pain or discomfort noting location, severity, duration, quality and radiation

Rationale Increased respiratory rate and use of accessory muscles may be seen in patients with hypoxia

Evaluation Patient has regular, even, non-labored respirations.

Changes in behavior and mental status can be early signs of impaired gas exchange which will result from decreased cardiac output

Patient will be alert, oriented x 3 and calm

Crackles may indicate heart failure which can contribute to decreased cardiac output. Respiratory distress/failure often occurs as shock progresses. A positive hepatojugular reflex is indicative of right-sided heart failure Increasing lethargy, confusion, restlessness and / or irritability can be early signs of cerebral hypoxia from decreased cardiac output Weight gain can be one of the earliest indicators of heart failure as a result of impaired ventricular pumping ability. An acute gain in weight of 1kg. can signal a l liter gain in fluid Sleep apnea is a common disorder in patients with chronic heart failure Chest pain is generally indicative of inadequate blood supply to the heart which can result in decreased cardiac output

Patients lungs sounds are clear to auscultation in all lobes Patient has normal hepatojugular reflex. Patient is awake, alert and oriented X3. Patient maintains baseline weight or less daily

Patient will have no episodes of sleep apnea Patient is free of chest pain.

Elevate legs when in Improves venous return and increases cardiac sitting position and output edematous extremities when at rest Monitor hourly urine output Decreased cardiac output results in decreased perfusion to the kidneys and decreased urine output. Urinary output < 30 ml/hr. indicates

Patient will have decreased edema in legs

Patient will have a minimum of 30ml/hr. urinary output

inadequate renal perfusion. Assess patient heart sounds Monitor patient for changes in heart rate and/or rhythm Assess peripheral pulses Observe patient for changes in skin color, moisture, temperature and capillary refill time Administer supplemental Oxygen as indicated by cannula, mask, or ET/trach tube. Promote rest Heart sounds may sound distant and have an S3 or S4 sound present with the presence of heart failure Heart irritability is common with conduction defects and/or ischemia from a poorly perfused heart (Tachycardia at rest, atrial fibrillation, bradycardia, or multiple dysrhythmias) Weak, thready peripheral pulses may reflect hypotension, vasoconstriction, shunting and venous congestion Pallor or cyanosis, cool moist skin and slow capillary refill time may be present from peripheral vasoconstriction and decreased oxygen saturation Supplemental oxygen helps to improve cardiac function by increasing available oxygen and reducing oxygen consumption Patient has normal heart sounds of S1 and S2 Patient will have normal sinus rhythm

Patient will have strong, palpable peripheral pulses in all extremities Patient will have normal skin color, be dry to touch and have capillary refill time of 3 seconds or less or 5 seconds or less (if patient is elderly) Patients oxygen saturation will remain at 93% or above at all times.

Rest and a quiet environment reduces a catecholamine-induced stress response and decreases cardiac workload thus increasing cardiac output Patient is often on multiple medications which can be difficult to manage, thus increasing the likelihood that medications can be missed or incorrectly used

Patient will get adequate rest in a stress-free environment.

Educate patient and caregivers about the importance of taking prescribed medications at prescribed times

Patient and/or caregiver will verbalize an understanding of patient medications and dosing schedule.