NURSING CARE PLAN

Decreased Cardiac Output related to altered heart rate and rhythm 2o MI

ASSESSMENT NURSING PLANNING NURSING ACTION RATIONALE EVALUATION

DIAGNOSIS
Subjective Cues: Decreased STG: Assessed for and document At the end of 8-hour
N/A Cardiac Output At the end of 30-min Nursing the ff: Nursing
related to altered Interventions, the client will o Mental Status Cerebral perfusion is Interventions, the
Objective Cues: heart rate and be able to: directly r/t cardiac output goal was partially
Generalized rhythm 2o MI Demonstrate and aortic perfusion met as evidenced
paleness hemodynamic stability pressure and is by:
noted (blood pressure and influenced by hypoxia
Irregular cardiac output) by 20% and electrolyte and acid- PR = 50s
rhythm of 30% as revealed in the base variation Cardiac monitoring
pulse noted cardiac monitor revealed
o Blood Pressure Hypotension r/t disturbance
LTG: hypoperfusion, vagal
At the end of 8-hour Nursing stimulation,
Interventions, the client will dysrhythmias, or
PR = 50s be able to: ventricular dysfunction
Demonstrate may occur
hemodynamic stability
(Blood pressure and o Heart Sounds
Bradycardia may be
cardiac output) by 31%-
present because of vagal
80% as revealed in the
stimulation or conduction
cardiac monitor
disturbances r/t area of
Manifest absence of
MI
angina
o Urine Output
Urine output
<0.5mL/kg/hrmay reflect
reduced renal perfusion

o Peripheral Perfusion
and glomerular filtration
as a result of reduced
cardiac output
Decreased may indicate
a decreased cardiac
output

Kept client on bed in Semi- Facilitate oxygenation

fowlers and administered
O2
Angina indicates
myocardial ischemia,
Monitored and assessed
which may decrease
angina for type, severity
cardiac ouput
and duration
To facilitate increase in
myocardial contractility
thus increasing cardiac
Administered beta-blockers ouput
and inotropin agents as
ordered

- Monitor cardiac rate, rythm

& conduction (report any
change)
- Observe vital signs, ECG,
urine output, skin temp &
colour
- Administer prophylactic anti-
arrhythmic & other drugs as
 ordered
- Administer IV fluids
- Promote physical & mental
rest & comfort
- Monitor laboratorium result
- Keep anti-dysrhythmic drugs
& defibrillator ready

Acute (Chest) Pain r/t myocardial ischemia resulting from coronary artery occlusion with loss/restriction of blood flow to an area of the myocardium and necrosis of
the myocardium.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVAULATION

Subjective: Acute (Chest) STG:
The client reports Pain r/t Within 1 hour of nursing INDEPENDENT: After nursing intervention,
of chest pain myocardial interventions, the client will assess characteristics of pain is indication of MI. the client had still had
ischemia have improved comfort in chest pain, including location, assisting the client in chest pain:
resulting from chest, as evidenced by: duration, quality, intensity, quantifying pain may Still displays tension,
Objective: coronary artery States a decrease in the presence of radiation, differentiate pre-existing and Still requires analgesia
Restlessness occlusion with rating of the chest pain. precipitating and alleviating current pain patterns as well or nitroglycerin.
Facial loss/restriction of Is able to rest, displays factors, and as associated as identify complications.
grimacing blood flow to an reduced tension, and symptoms, have client rate
Fatigue area of the sleeps comfortably. pain on a scale of 1-10 and Goal unmet
myocardium and Requires decrease document findings in nurses
Peripheral
necrosis of the analgesia or nitroglycerin. notes.
cyanosis
myocardium.
Weak pulse
LTG: obtain history of previous this provides information that
Cold and cardiac pain and familial may help to differentiate
The client will have an
clammy skin history of cardiac problems. current pain from previous
improved feeling of control
Palpitations problems and complications.
as evidenced by verbalizing
 Shortness of a sense of control over
breath present situation and future
Pain scale of outcomes within 2 days of assess respirations, BP and
10/10 nursing interventions. heart rate with each episodes
Levines sign of chest pain.
maintain bedrest during pain,
with position of comfort,
maintain relaxing
environment to promote
calmness.
prepare for the administration
of medications, and monitor
response to drug therapy.
Notify physician if pain does
not abate.
instruct patient/family in
medication effects, side-
effects and contraindications
contraindications
DEPENDENT:
obtain a 12-lead ECG on
admission, then each time
chest pain recurs for
evidence of further infarction
as prescribed.
administer analgesics as
respirations may be
increased as a result of pain
and associate anxiety.
to reduce oxygen
consumption and demand,
to reduce competing stimuli
and reduces anxiety.
pain control is a priority, as it
indicates ischemia.
to promote knowledge with
therapeutic regimen and to
alleviate fear of unknown.
ECG and stat ECGs record
changes that can give
evidence of further cardiac
damage and location of MI.
analgesics may be used to
 ordered reduce pain and reduce the
workload on the heart.

administer beta-blockers as to block sympathetic

ordered. stimulation, reduce heart
rate and lowers myocardial
demand.

administer calcium-channel to increase coronary blood

blockers as ordered. flow and collateral circulation
which can decrease pain
due to ischemia.

Impaired tissue perfusion related to hypovolemia secondary to decreased cardiac output ; decreased hemoglobin concentration in blood secondary tp
chronic anemia

ASSESSMENT DIAGNOSIS PLANNING INRTERVENTION RATIONALE EVALUATION

SUBJECTIVE; Impaired tissue INDEPENDENT: After nursing intervention:
N/A perfusion related STG:
to hypovolemia Monitor neurological status; New onset of these -the client still displays
OBJECTIVE: secondary to Demonstrates adequate do a neurological examination neurological symptoms can pale, cold, clammy skin
decreased cardiac tissue perfusion as signify a stroke. If caused by -still with weal peripheral
Hematuria output ; decreased evidenced by palpable a thrombus and the client pulses
Edema hemoglobin peripheral pulses, warm and receives treatment within 3 -decreased gcs score
weak or absent concentration in dry skin, adequate urinary hours, a stroke can often be
pulses blood secondary output, and the absence of reversed.
skin color pale tp chronic anemia respiratory distress
on elevation, Note skin color and feel Skin pallor or mottling, cool
color does not temperature of the skin. or cold skin temperature, or
return on an absent pulse can signal
lowering the leg arterial obstruction, which is
Speech an emergency that requires
abnormalities immediate intervention.
extremity
weakness Check capillary refill. Nail beds usually return to a
altered mental pinkish color within 3
status seconds after nail bed
changes in compression (Dykes, 1993).
motor response
chest pain Monitor peripheral pulses. If These are symptoms of
dyspnea new onset of loss of pulses arterial obstruction that can
with bluish, purple, or black result in loss of a limb if not
areas and extreme pain, immediately reversed.
notify physician immediately.

DEPENDENT
Blood transfusion therapy -to correct hemoglobin and
hematocrit levels; improve
oxygenation

To increase circulating blood

Hydration with fluid volume volume
replacement