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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVAUATION

Assess for abnormal heart Shallow, rapid respirations are characteristics


SUBJECTIVE: and lung sounds. of decreased cardiac output. Crackles indicate Short term:
“Sobrang bilis ng Decreased Cardiac Short term: Patient fluid buildup secondary to impaired left Goal partially
tibok ng puso ko, as Output related to will demonstrate ventricular emptying. met, patient
verbalized by the altered myocardial adequate cardiac S1 and S2 may be weak because of diminished demonstrated
patient.” contractility output as evidenced pumping action. Gallop rhythms are common signs of
by vital signs within (S3and S4), produced as blood flows into adequate
normal range, noncompliant chambers. Murmurs may reflect cardiac output
OBJECTIVE: regular pulse rate, valvular incompetence. as evidenced by
good capillary refill, Check for peripheral normal pulse
 Nausea and normal urine pulses, including capillary Decreased cardiac output may be reflected in rate, good
 Weakness output. refill. diminished peripheral pulses. Weak pulses are capillary refill,
 Tachycardia present in reduced stroke volume and cardiac absence of
180 bpm Long term: Patient output. Capillary refill is sometimes slow or pallor, and urine
 Dyspnea 26 will convert back to absent. output of 700
cpm Normal Sinus Rhythm In early, moderate, or chronic HF, BP may be ml of urine in 8
 (+) Crackles as evidenced by Monitor BP. elevated because of increased SVR. In hours.
 BP 190/100 normal ECG result advanced HF, the body may no longer be able RR: 26
to compensate, and PR: 95
profound hypotension may occur BP: 140/90

Pallor is indicative of diminished peripheral


Inspect skin for pallor. perfusion secondary to inadequate cardiac
output.

Monitor urine output Kidneys respond to reduced cardiac output by


retaining water and sodium. Oliguria is a
classic sign of decreased renal perfusion.

Review patient’s EKG. EKG can reveal previous MI, or evidence of left
ventricular hypertrophy, indicating aortic
stenosis or chronic systemic hypertension.
Check symptoms for
chest pain. Low cardiac output can further decrease
myocardial perfusion, resulting in chest pain.
Note changes in
sensorium:
lethargy, confusion, May indicate inadequate cerebral perfusion
disorientation, anxiety, secondary to decreased cardiac output.
and depression.

Administer supplemental
oxygen as indicated.
Increases available oxygen for myocardial
Give anti-arrhythmic drug uptake to combat effects of hypoxia.
as prescribed
Amiodarone is a primarily a class III
antiarrhythmic. Like other antiarrhythmic
drugs of this class, it works primarily by
blocking potassium rectifier currents that are
responsible for repolarization of the heart
Give anti-hypertensive during phase 3 of the cardiac action potential.
drug as ordered
It works by relaxing blood vessels so blood can
flow more easily and helps prevent strokes
Monitor bowel function. and heart attacks.
Provide stool softeners as
ordered. Tell patient to Straining when defecating that results in the
avoid straining when Valsalva maneuver can lead to dysrhythmia,
defecating. decreased cardiac function, and sometimes
death.
Provide quiet
environment: explain
therapeutic management, Psychological rest helps reduce emotional
help patient avoid stress, which can produce vasoconstriction,
stressful elevating BP and increasing heart rate.
situations, listen and
respond to expressions of
feelings.

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