COLLABORATIVE DIAGNOSIS: Potential complications

  1. renal insufficiency related to a prolonged or severe decrease in renal blood flow associated with low cardiac output, volume depletion (a result of third-spacing and/or excessive diuretic use), and vasodilator-induced hypotension;
  2. cardiac dysrhythmias related to impaired nodal function and/or altered myocardial conductivity associated with hypoxia, sympathetic nervous system stimulation (a compensatory response to low cardiac output), structural changes in the myocardium (e.g. dilation, hypertrophy), and electrolyte imbalances (particularly the magnesium and potassium depletion that can result from diuretic therapy);
  3. acute pulmonary edema related to accumulation of fluid in the lungs associated with increased hydrostatic pressure in the pulmonary vessels as a result of blood flow back up in the left ventricle;
  4. thromboembolism related to:
    1. venous stasis in the periphery associated with decreased cardiac output and decreased mobility
    2. stasis of blood in the heart associated with decreased ventricular emptying (risk increases if dysrhythmias are present);
  5. cardiogenic shock related to inability of heart, intrinsic compensatory mechanisms, and treatments to maintain adequate tissue perfusion to vital organs.
Desired Outcome
The client will maintain adequate renal function as evidenced by:
  1. urine output at least 30 ml/hour
  2. BUN, serum creatinine, and creatinine clearance within normal range.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of impaired renal function (e.g. urine output less than 30 ml/hour, urine specific gravity fixed at or less than 1.010, elevated BUN and serum creatinine levels, decreased creatinine clearance).
  2. Implement measures to maintain adequate renal blood flow:
    1. perform actions to improve cardiac output (see Diagnosis 1, action b)
    2. perform actions to reduce third-spacing (see Diagnosis 3, action D.2) in order to prevent hypovolemia
    3. ensure a minimum fluid intake of 1000 ml/day unless ordered otherwise
    4. consult physician before giving vasodilators and diuretics if client is hypotensive.
  3. If signs and symptoms of impaired renal function occur:
    1. consult physician about possible need to reduce the digitalis dosage (digitalis is excreted by the kidney and will quickly reach toxic levels when renal function is impaired)
    2. consult physician about lowering the dose of or discontinuing angiotensin-converting enzyme inhibitors and diuretics if BUN and serum creatinine continue to rise significantly (ACE inhibitors and many diuretics should be used cautiously in persons with impaired renal function because they can have an adverse effect on renal function)
    3. assess for and report signs of acute renal failure (e.g. oliguria or anuria; further weight gain; increasing edema; increased B/P; lethargy and confusion; increasing BUN and serum creatinine, phosphorus, and potassium levels)
    4. prepare client for dialysis if indicated.
Desired Outcome
The client will maintain normal sinus rhythm as evidenced by:
  1. regular apical pulse at 60 - 100 beats/minute
  2. equal apical and radial pulse rates
  3. absence of syncope and palpitations
  4. ECG reading showing normal sinus rhythm.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of cardiac dysrhythmias (e.g. irregular apical pulse; pulse rate below 60 or above 100 beats/minute; apical-radial pulse deficit; syncope; palpitations; abnormal rate, rhythm, or configurations on ECG).
  2. Implement measures to prevent cardiac dysrhythmias:
    1. perform actions to improve cardiac output (see Diagnosis 1, action b) in order to promote adequate myocardial tissue perfusion and oxygenation
    2. perform actions to improve respiratory status (see Diagnosis 2, action b) in order to improve tissue oxygenation
    3. consult physician regarding an order for a potassium or magnesium replacement if serum levels of either are below normal.
  3. If cardiac dysrhythmias occur:
    1. initiate cardiac monitoring if not already being done
    2. administer antidysrhythmics (e.g. digoxin, amiodarone) if ordered
    3. restrict client's activity based on his/her tolerance and severity of the dysrhythmia
    4. maintain oxygen therapy as ordered
    5. assess cardiovascular status frequently and report signs and symptoms of a further decline in cardiac output and tissue perfusion
    6. prepare client for catheter ablation or insertion of a pacemaker or implantable cardioverter defibrillator (ICD) if planned
    7. have emergency cart readily available for cardioversion, defibrillation, or cardiopulmonary resuscitation.
Desired Outcome
The client will not develop acute pulmonary edema as evidenced by:
  1. decreased dyspnea
  2. usual or improved breath sounds
  3. usual mental status
  4. blood gases within normal range.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of acute pulmonary edema:
    1. sudden development of or increased dyspnea or orthopnea
    2. development of or increased crackles (rales) or wheezes
    3. increased restlessness and anxiousness, disorientation
    4. cough productive of frothy or blood-tinged sputum
    5. significant decrease in oximetry results
    6. worsening blood gas results
    7. chest x-ray showing pulmonary edema.
  2. Implement measures to improve cardiac output (see Diagnosis 1, action b) in order to reduce pulmonary vascular congestion.
  3. If signs and symptoms of pulmonary edema occur:
    1. place client in a high Fowler's position unless contraindicated
    2. maintain oxygen therapy as ordered
    3. administer the following medications if ordered:
      1. diuretics (e.g. furosemide, bumetanide) to reduce fluid accumulation in the lungs
      2. theophylline to dilate the bronchioles; it also increases cardiac and urine output, which subsequently reduces pulmonary vascular congestion
      3. morphine sulfate to reduce anxiety and decrease pulmonary vascular congestion (increases venous capacitance, which lowers venous return to the heart)
      4. vasodilators (e.g. sodium nitroprusside, nitroglycerin) to reduce afterload and improve left ventricular emptying, which reduces pulmonary blood flow backup.
Desired Outcome
The client will not develop a thromboembolism as evidenced by:
  1. absence of pain, tenderness, swelling, and numbness in extremities
  2. usual temperature and color of extremities
  3. palpable and equal peripheral pulses
  4. usual mental status
  5. usual sensory and motor function
  6. absence of sudden chest pain and increased dyspnea.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of:
    1. deep vein thrombus (e.g. pain, tenderness, swelling, unusual warmth, and/or positive Homans' sign in extremity)
    2. arterial embolus in an extremity (e.g. diminished or absent peripheral pulses; pallor, coolness, numbness, and/or pain in extremity)
    3. cerebral ischemia (e.g. decreased level of consciousness, alteration in usual sensory and motor function)
    4. pulmonary embolism (e.g. sudden onset of chest pain, increased dyspnea, increased restlessness and apprehension, significant decrease in SaO2).
  2. Implement measures to prevent and treat a deep vein thrombus and pulmonary embolism (see Care Plan on Immobility, Diagnosis 12).
  3. Implement additional measures to prevent the development of thromboemboli:
    1. perform actions to improve cardiac output (see Diagnosis 1, action b)
    2. perform actions to treat cardiac dysrhythmias if present (see action C in the dysrhythmias complication)
    3. administer anticoagulants (e.g. warfarin, low- or adjusted-dose heparin, low-molecular-weight heparin) or antiplatelet agents (e.g. low-dose aspirin) if ordered.
  4. If signs and symptoms of an arterial embolus in an extremity occur:
    1. maintain client on bed rest with affected extremity in a level or slightly dependent position to improve arterial blood flow
    2. prepare client for the following if planned:
      1. diagnostic studies (e.g. Doppler or duplex ultrasound, arteriography)
      2. injection of a thrombolytic agent (e.g. streptokinase)
      3. embolectomy
    3. administer anticoagulants (e.g. continuous intravenous heparin, warfarin) as ordered.
  5. If signs and symptoms of cerebral ischemia occur:
    1. maintain client on bed rest; keep head and neck in neutral, midline position
    2. administer anticoagulants (e.g. continuous intravenous heparin, warfarin) as ordered.
Desired Outcome
The client will not develop cardiogenic shock as evidenced by:
  1. stable or improved mental status
  2. systolic B/P greater than 80 mm Hg
  3. palpable peripheral pulses
  4. stable or improved skin temperature and color
  5. urine output at least 30 ml/hour
  6. pulmonary capillary wedge pressure (PCWP) between 15 - 20 mm Hg
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and immediately report signs and symptoms of cardiogenic shock:
    1. increased restlessness, lethargy, or confusion
    2. systolic B/P below 80 mm Hg
    3. rapid, weak pulse
    4. diminished or absent peripheral pulses
    5. increased coolness and duskiness or cyanosis of skin
    6. urine output less than 30 ml/hour
    7. PCWP greater than 20 mm Hg.
  2. Implement measures to prevent cardiogenic shock:
    1. perform actions to improve cardiac output (see Diagnosis 1, action b)
    2. perform actions to treat cardiac dysrhythmias if present (see action C in the dysrhythmias complication).
  3. If signs and symptoms of cardiogenic shock occur:
    1. maintain oxygen therapy as ordered
    2. administer the following medications if ordered:
      1. sympathomimetics (e.g. dopamine, dobutamine, norepinephrine) to increase cardiac output and maintain arterial pressure
      2. vasodilators (e.g. sodium nitroprusside, nitroglycerin) to decrease cardiac workload (the use of vasodilators will be determined by the client's blood pressure and PCWP and usually not be given if the systolic B/P is less than 100 mm Hg or the PCWP is less than 15 mm Hg)
    3. assist with intubation and insertion of hemodynamic monitoring device (e.g. Swan-Ganz catheter) and intra-aortic balloon pump (IABP) if indicated.