NURSING DIAGNOSIS: Decreased cardiac output

related to:
  1. pre-existing compromise in cardiac function;
  2. trauma to the heart during surgery;
  3. increased afterload associated with:
    1. vasoconstriction resulting from hypothermia and an increase in catecholamine output and plasma renin levels (these increases occur with cardiopulmonary bypass and the effect of stressors [e.g. pain, anxiety])
    2. fluid overload;
  4. decreased preload associated with:
    1. hypovolemia (can result from blood loss, fluid shifting from the intravascular to interstitial space, loss of fluid from nasogastric tube, decreased fluid intake, and excessive diuresis)
    2. hypotension (can occur if body is warmed rapidly following surgery and as a result of the effect of anesthesia and certain medications [e.g. narcotic analgesics, beta-adrenergic blockers, vasodilators]);
  5. effects of hypothermia, hypoxemia, and acid-base and/or electrolyte imbalances on contractility and conductivity of the heart.
Desired Outcome
The client will maintain adequate cardiac output as evidenced by:
  1. B/P within range of 130 - 100/80 - 60
  2. apical pulse regular and between 60 -100 beats/minute
  3. absence of or no increase in intensity of gallop rhythm
  4. increased strength and activity tolerance
  5. unlabored respirations at 12 - 20/minute
  6. absence of adventitious breath sounds
  7. usual mental status
  8. absence of dizziness and syncope
  9. palpable peripheral pulses
  10. skin warm and usual color
  11. capillary refill time less than 3 seconds
  12. urine output at least 30 ml/hour
  13. absence of edema and jugular vein distention
  14. hemodynamic measurements such as pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), and central venous pressure (CVP) within normal limits.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of:
    1. hypovolemia (e.g. low B/P; resting pulse rate greater than 100 beats/ minute; postural hypotension; cool, pale, or cyanotic skin; diminished or absent peripheral pulses; urine output less than 30 ml/hour; low CVP)
    2. hypotension (systolic B/P persistently below 100 mm Hg)
    3. decreased cardiac output:
      1. variations in B/P (may be increased because of compensatory vasoconstriction; may be decreased when compensatory mechanisms and pump fail)
      2. tachycardia
      3. presence of gallop rhythm
      4. fatigue and weakness
      5. dyspnea, tachypnea
      6. crackles (rales)
      7. restlessness, change in mental status
      8. dizziness, syncope
      9. diminished or absent peripheral pulses
      10. cool extremities
      11. pallor or cyanosis of skin
      12. capillary refill time greater than 3 seconds
      13. oliguria
      14. edema
      15. jugular vein distention (JVD)
      16. hemodynamic abnormalities such as increased PAP, PCWP, and CVP (use internal jugular vein pulsation method to estimate CVP if monitoring device not present); these values will be low if hypovolemia is the cause of low cardiac output
      17. chest x-ray results showing pulmonary vascular congestion, pulmonary edema, or pleural effusion
      18. abnormal blood gases
      19. significant decrease in oximetry results
    4. dysrhythmias (e.g. irregular heart rate; heart rate less than 60 or greater than 100; abnormal rate, rhythm, or configurations on the ECG).
  2. Implement measures to maintain an adequate cardiac output:
    1. perform actions to prevent or treat hypovolemia:
      1. administer blood and/or colloid or crystalloid solutions as ordered
      2. maintain a minimum fluid intake of 1000 ml/day unless ordered otherwise
      3. implement measures to prevent and control bleeding (see Postoperative Diagnosis 6, actions D and E in the bleeding complication)
    2. perform actions to prevent or treat hypotension:
      1. consult physician before giving negative inotropic agents, diuretics, and vasodilating agents if client is hypotensive
      2. administer narcotic (opioid) analgesics judiciously; in the immediate postoperative period, be alert to the synergistic effect of the narcotic ordered and the anesthetic that was used during surgery
      3. avoid rapid rewarming; gradually bring client's body temperature to normal if he/she is hypothermic
      4. administer sympathomimetics (e.g. dopamine) if ordered
    3. administer positive inotropic agents (e.g. dopamine, dobutamine, digitalis preparations) if ordered to increase myocardial contractility
    4. perform actions to prevent or treat cardiac dysrhythmias (see Postoperative Diagnosis 6, actions B and C in the dysrhythmias complication)
    5. perform actions to reduce cardiac workload:
      1. place client in a semi- to high Fowler's position
      2. perform actions to prevent or treat hypertension:
        1. implement measures to warm client (e.g. increase room temperature, apply warm blankets) if he/she is hypothermic (helps prevent vasoconstriction associated with hypothermia and also prevents shivering, which elevates the metabolic rate and increases cardiac workload)
        2. implement measures to reduce stress (e.g. initiate pain relief measures, reduce fear and anxiety)
        3. administer vasodilators (e.g. sodium nitroprusside, nitroglycerin) if ordered
      3. instruct client to avoid activities that create a Valsalva response (e.g. straining to have a bowel movement, holding breath while moving up in bed)
      4. implement measures to promote rest (e.g. maintain activity restrictions, administer prescribed pain medications, limit the number of visitors, reduce anxiety)
      5. implement measures to maintain adequate respiratory function (see Postoperative Diagnosis 2, action b) in order to promote adequate tissue oxygenation
      6. discourage smoking (nicotine has a cardiostimulatory effect and causes vasoconstriction; the carbon monoxide in smoke reduces oxygen availability)
      7. discourage excessive intake of beverages high in caffeine such as coffee, tea, and colas (caffeine is a myocardial stimulant and can increase myocardial oxygen consumption)
      8. implement measures to prevent or treat fluid volume excess (see Postoperative Diagnosis 3)
      9. increase activity gradually as allowed and tolerated.
  3. Consult physician if signs and symptoms of decreased cardiac output persist or worsen.