Cardiac Output, Decreased
Meg Gulanick, RN,
NANDA: A state in which the blood pumped by an individual's heart
is sufficiently reduced that it is inadequate to meet the needs of the body's
Common causes of reduced cardiac output include myocardial
infarction, hypertension, valvular heart disease, congenital heart disease,
cardiomyopathy, pulmonary disease, arrhythmias, drug effects, fluid overload,
decreased fluid volume, and electrolyte imbalance. Geriatric patients are
especially at risk, because the aging process causes reduced compliance of the
ventricles, which further reduces contractility and cardiac output. Patients
may have acute, temporary problems or experience chronic, debilitating effects
of decreased cardiac output. Patients may be managed in an acute, ambulatory
care, or home care setting. This care plan focuses on the acute management.
- Increased or decreased ventricular filling (preload)
- Alteration in afterload
- Impaired contractility
- Alteration in heart rate, rhythm, and conduction
- Decreased oxygenation
- Cardiac muscle disease
- Variations in hemodynamic parameters (blood pressure [BP],
heart rate, cardiovascular pressure [CVP], pulmonary artery pressures, venous
oxygen saturation [S VO2],
- Arrhythmias, electrocardiogram (ECG) changes
- Rales, tachypnea, dyspnea, orthopnea, cough, abnormal arterial
blood gases (ABGs), frothy sputum
- Weight gain, edema, decreased urine output
- Anxiety, restlessness
- Syncope, dizziness
- Weakness, fatigue
- Abnormal heart sounds
- Decreased peripheral pulses, cold clammy skin
- Confusion, change in mental status
- Ejection fraction less than 40%
- Pulsus alternans
Patient maintains BP within normal limits; warm, dry skin;
regular cardiac rhythm; clear lung sounds; and strong bilateral, equal
- (i) independent
- (i) Assess mentation.
- Restlessness is noted in the early stages; severe anxiety
and confusion are seen in later stages.
- (i) Assess heart rate and blood
- 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, thus their response to
reduced cardiac output may be blunted, with less rise in heart rate. Pulsus
alternans (alternating strong-then-weak pulse) if often seen in heart failure
- (i) Assess skin color and
- Cold, clammy skin is secondary to compensatory increase in
sympathetic nervous system stimulation and low cardiac output and
- (i) Assess peripheral pulses.
- Pulses are weak with reduced cardiac output.
- (i) Assess fluid balance and weight
- 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.
- (i) Assess heart sounds, noting gallops,
- 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
- (i) 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.
- (c) If hemodynamic monitoring is in
- Monitor central venous, right arterial pressure [RAP],
pulmonary arterial 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
- Monitor SVO2
- Change in oxygen saturation of mixed venous blood is
one of the earliest indicators of reduced cardiac output.
- Perform cardiac output determination.
- Provides objective number to guide therapy.
- (i) Monitor continuous ECG as appropriate.
- (i) 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.
- (i) Assess response to increased
- Physical activity increases the demands placed on the
heart; fatigue and exertional dyspnea are common problems with low cardiac
output states. Close monitoring of patient's response serves as a guide for
optimal progression of activity.
- (i) Assess urine output. Determine how
often the patient urinates.
- Oliguria can reflect decreased renal perfusion. Diuresis is
expected with diuretic therapy.
- (i) Assess for chest pain.
- Indicates an imbalance between oxygen supply and
- (i) Assess contributing factors so
appropriate plan of care can be initiated.
- (i) independent
- (c) Administer medication as prescribed,
noting response and watching for side effects and toxicity. Clarify with
physician parameters for withholding medications.
- Depending on etiologic factors, common medications include
digitalis therapy, diuretics, vasodilator therapy, antidysrhythmics, ace
inhibitors, and inotropic agents.
- (c) 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.
- (c) Maintain hemodynamic parameters at
- For patients in the acute setting, close monitoring of
these parameters guides titration of fluids and medications.
- (c) For patients with increased preload,
restrict fluids and sodium as ordered.
- To decrease extracellular fluid volume.
- (c) Maintain adequate ventilation and
perfusion, as in the following:
- Place patient in semi- to high-Fowler's position
- To reduce preload and ventricular filling.
- Place in supine position
- To increase venous return, promote diuresis.
- Administer humidified O2 as ordered.
- The failing heart may not be able to respond to
- (c) Maintain physical and emotional rest, as
in the following:
- Restrict activity
- Provide quiet, relaxed environment.
- Emotional stress increases cardiac demands.
- Organize nursing and medical care
- Monitor progressive activity within limits of cardiac
- (c) Administer stool softeners as needed.
- Straining for a bowel movement further impairs cardiac
- (c) Monitor sleep patterns; administer
- Rest is important for conserving energy.
- (c) If arrhythmia occurs, determine
patient response, document, and report if significant or symptomatic.
- Both tachyarrhythmias and bradyarrhythmias can reduce
cardiac output and myocardial tissue perfusion.
- Have antiarrhythmic drugs readily available.
- Treat arrhythmias according to medical orders or protocol and
- (c) If invasive adjunct therapies are
indicated (e.g., intra-aortic balloon pump, pacemaker), maintain within
Education/Continuity of Care
- (i) independent
- (i) Explain symptoms and interventions for
decreased cardiac output related to etiologic factors.
- (i) Explain drug regimen, purpose, dose,
and side effects.
- (i) Explain progressive activity schedule
and signs of overexertion.
- (i) Explain diet restrictions (fluid,
Cardiac Care; Hemodynamic Regulation; Teaching: Disease
- See also:
- Fluid Volume Deficit, Chapter
3, p. 84
- Myocardial Infarction, Chapter 4, p. 328
- Cardiogenic Shock, Chapter 4, p. 385
- Cardiac Dysrhythmias, Chapter 4, p.295
- Chest Trauma, Chapter 5, p. 447
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