Assessment
Explanation of the
problem
Objectives
Subjective:
"Nahihilo ako, dito
banda din masakit sa
ulo ko"
"Tulong ako paupo"
"Nasusuka ako"
"Mas gusto ko pa
punta na langit, kaysa
hirap"
Marilyn Doenges'
Nurse's Pocket Guide
defined Decreased
Cardiac Output by
inadequate blood
pumped by the heart
to meet the metabolic
demands of the body.
The patient has mitral
valve regurgitation,
left atrial dilatation,
left ventricular
hypertrophy,
decreased septal
flexibility and aortal
regurgitation. This
altered cardiac
structure causes an
impairement in the
ability of the heart to
pump adequate blood
and produce enough
cardiac output and
these results to
decreased cardiac
output. Cardiac output
is the volume of blood
pumped by the heart
Short term
objective:
After 8 hours of
nursing intervention,
the patient will
participate in
activities that
reduce the
workload of the
heart such as
stress
management
or therapeutic
medication
regimen
would not
manifest
nausea,
flushed skin,
and no
complain of
easy
fatigability,
with pinkish
nail beds
Long term
objective:
after 72 hours of
Objective:
-CKD stage 5
-VS: Bp- 170/80, PR85, RR - 20, T- 36.5
and SPO2 - 96%
-According to Dr.
Olarte's Asessment:
1) Left ventricular
Hypertrophy
2) Mitral and Aortic
Sclerosis with
regurgitation
3) Minimal Pericardial
Effusion
4) Atherosclerotic
Knob
- Fatigue
- Flushed skin
intervention
Dx:
Monitor vital signs
especially heart rate
and BP
Assesse accurate
intake and output.
Include hidden
fluids, such as
intravenous antibiotic
additives, liquid
medication, ice chips,
and frozen treats.
Measures GI losses
Monitor for weigh
daily at same scale,
with same equipment
and clothing
Assess skin, face, and
dependent areas for
edema. Evaluate
degree of edema ( on
Rationale
Obtain baseline data.
Fluid volume excess,
combined with
hypertension, which
often occurs in renal
failure, and effects of
uremia increase
cardiac workload and
can lead to cardiac
failure.
Accurate I and O are
necessary for
determining fluid
replacement needs
and reducing risk of
fluid overload.
Daily body weight is
best monitor of fluid
status. A weight gain
of more than 0.5
kg/day suggest fluid
retention.
Edema occurs
primarily in
dependent tissues of
the body, such as
evaluation
Fully Met if:
If the client displayed
hemodynamic
stability as
manifested by:
- Decreased Blood
Pressure
- Adequate Cardiac
Output
- Presence of Urinary
Output
- Normal Peripheral
Pulses.
STO:
If the client
participated in the
activities that reduces
the workload of the
heart.
Partially met if:
LTO:
If the client displays
only 1 or two
manifestations of
hemodynamic
stability.heart.
- Pail nailbeds
- Capillary refill 1-2
seconds
- Sense of impending
doom
- Nauseated
- Non-compliant to
take medications such
as:
1) Vitamin B12 tab
2) FeSo4 tab
3) Sertraline tab
P> Decrease
Cardiac Output
Related To
Alteration In
Cardiac Structures
per minute. Cardiac
output is a function of
heart rate and stroke
volume. Decrease
Cardiac Output is
manifested to the
patient as weakness,
dizziness, headache,
as a signs of Fatigue,
high blood pressure of
170/80 mmhg, and
pale nailbeds.
nursing intervention
the patient will able to
display hemodynamic
stability as
manifested by:
decreased
blood pressure
of 150/80 from
170/80
adequate
cardiac output
adequate
urinary output
of 30 ml/hr
normal
peripheral
pulses
scale of +1 to +4)
Auscultate lung and
heart sounds
Assessed on
occurrence of muscle
cramps, numbness or
tingling of fingers
Assess presence and
degree of
hypertension: monitor
BP and note postural
changes, such as
sitting lying, and
standing
hands, feet, and
lumbosacral area.
Fluid overload may
lead to pulmonary
edema and HF, as
evidenced by
development of
adventitious breath
sounds and extra
heart sound
These are the
symptoms of
hypocalcemia.
Calcium levels are
typically somewhat
decreased
Significant
hypertension can
occur because of
disturbance in the
renin-angiotensinaldosterone system
caused by renal
dysfunction.
Not met if:
If the client still did
not displayed any
improvement in the
Blood Pressure,
Cardiac Output,
Urinary Output and
Pulse.
STO:
If the client did no
participate in any
activities that can
reduce the workload
of the heart.
Assess color of skin,
mucous membranes,
and nail beds. Note
capillary refill time
Evaluate client reports
and evidence of
extreme fatigue,
intolerance for activity
Tx:
Maintain bed rest and
provide assistance
with care and desired
activities
Provide psychological
support. And
maintained calm
attitude
Pallor may reflect
vasoconstriction or
anemia- common in
ARF, whether
associated with actual
blood loss or
abnormalities in life
RBCs. Cyanosis is a
late sign and is
related to pulmonary
congestion or cardiac
failure. A long
capillary refill time is
associated with
hypovolemic states
To assess for signs of
poor ventricular
function and/or
impending cardiac
failure.
Decrease metabolic
demands on the body.
Reduces oxygen
consumption and
cardiac workload.
Provide honesty and
intimacy to the
patient
Observed ECG or
telemetry for changes
in rhythm
ED:
Instructed to limit
fluid intake to
prescribed volume
Explained to patient
and family the
rationale for fluid
restriction
Encourage to limit or
restrict foods rich in
protein such as fish,
meats
instructed to low
sodium diet
Instructed to increase
food rich in
carbohydrates such
as bread, rice, pasta
Changes in
electromechanical
function may become
evident in response to
accumulation of
toxins and electrolyte
imbalance.
Fluid restriction will be
determined on basis
of weight, urine
output, and response
to therapy
Understanding
promotes patient and
family cooperation
with fluid restriction
If the kidneys are not
working correctly,
then urea is not
excreted and BUN will
go up.
Sodium causes fluid
retention
Improves energy and
to prevent body from
breaking down protein
for energy
