NURSING DIAGNOSIS: Risk for decreased cardiac output

related to possible decreased contractility and altered conductivity of the heart associated with the myocardial damage that has occurred with infarction.

Desired Outcome
The client will have adequate cardiac output as evidenced by:
  1. B/P within normal range for client
  2. apical pulse between 60 - 100 beats/minute and regular
  3. resolution of gallop rhythm(s)
  4. no reports of fatigue and weakness
  5. unlabored respirations at 12 - 20/minute
  6. clear, audible 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.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report the following:
    1. diagnostic findings indicative of an MI:
      1. elevated CK (CPK)-MB
      2. elevated troponin levels
      3. elevated LDH with an LDH1 level that is higher than the LDH2 (a reliable indicator of an acute MI)
      4. ECG showing ST segment elevation or depression, peaked T waves or inversion of T waves, and/or presence of abnormal Q waves (there may be no Q waves if client has had a subendocardial infarction)
      5. presence of an S4 heart sound
    2. signs and symptoms of decreased cardiac output:
      1. variations in B/P (may be increased because of pain or compensatory vasoconstriction; may be decreased when compensatory mechanisms and pump fail)
      2. tachycardia
      3. presence of gallop rhythm(s)
      4. fatigue and weakness
      5. dyspnea, orthopnea, tachypnea
      6. crackles (rales)
      7. restlessness, anxiousness, confusion, or other 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. chest x-ray results showing pulmonary vascular congestion, pulmonary edema, or pleural effusion
      17. abnormal blood gases
      18. significant decrease in oximetry results.
  2. Implement measures to maintain an adequate cardiac output:
    1. prepare client for procedures that may be performed to improve coronary blood flow:
      1. injection of a thrombolytic agent (e.g. streptokinase, alteplase [tPA], anistreplase [APSAC, Eminase], reteplase)
      2. percutaneous coronary revascularization (e.g. balloon angioplasty, atherectomy, intracoronary stenting)
      3. insertion of an intra-aortic balloon pump (IABP)
    2. perform actions to reduce cardiac workload:
      1. place client in a semi- to high Fowler's position
      2. 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)
      3. implement measures to promote rest and conserve energy (see Diagnosis 3, action b.1)
      4. maintain oxygen therapy as ordered
      5. discourage smoking (nicotine has a cardiostimulatory effect and causes vasoconstriction; the carbon monoxide in smoke reduces oxygen availability)
      6. provide small meals rather than large ones (large meals require a greater increase in blood supply to gastrointestinal tract for digestion)
      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. restrict sodium intake if ordered to prevent fluid retention
      9. increase activity gradually as allowed and tolerated
    3. administer the following medications if ordered:
      1. nitrates (e.g. nitroglycerin) to dilate the coronary and peripheral (primarily venous) blood vessels and subsequently improve coronary blood flow and reduce cardiac workload and myocardial oxygen requirements
      2. beta-adrenergic blocking agents (e.g. atenolol, metoprolol) to decrease the incidence of dysrhythmias and to reduce myocardial oxygen requirements by decreasing heart rate and the force of myocardial contractility; beta blockers also appear to limit infarct size and reduce short- and long-term cardiac morbidity and mortality
      3. angiotensin-converting enzyme (ACE) inhibitors such as captopril and ramipril (have been shown to limit infarct size and reduce ventricular remodeling and the incidence of heart failure following myocardial infarction)
      4. antidysrhythmics (e.g. lidocaine, procainamide, metoprolol, atenolol, amiodarone, diltiazem, atropine) if dysrhythmias are present
      5. anticoagulants (e.g. intravenous heparin) and antiplatelet agents (e.g. low-dose aspirin, clopidogrel) to reduce the incidence of reinfarction and ventricular thrombus formation.
  3. Consult physician if signs and symptoms of decreased cardiac output persist or worsen.