Date Formulated: January 14, 2015

Nursing Diagnosis (NANDA Approved): Decreased

cardiac output related to decreased

venous return
Level of prioritization: High
Reason/ Cause Analysis: Decreased cardiac output is 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 tissues. Common causes of reduced cardiac output

include hypertension Patients may have acute, temporary problems or

experience chronic, debilitating effects of decreased cardiac output.
Reference:
Goal: Patient maintains BP within normal limits

CUES

Subjective:
Luya kaayu
siya, sige lang
ug tulog as
verbalized by
the SO.

Objective:
>BP:
>Edematous

>Capillary
refill: 5
seconds

>Weakness
>Fatigue

DESIRED
OUTCOME

Short term:
After 8
hours of
nursing
interventio
ns, the
patient will
participate
in activities
that reduce
blood
pressure or
cardiac
work load.
Long Term:

NURSING
INTERVENTIONS

RATIONALE

EVALUATION

Comparison
of pressures
provides a
more
complete
picture of
vascular
involvement or
scope of the
problem.

Short Term:
After 8 hours
of nursing
interventions,
the patient
was able to
participate in
activities that
reduce blood
pressure or
cardiac work
load

Independent:
Monitor blood
pressure of the
patient.
Measure in both
arms or thighs
three times, 3-5
minutes apart
while patient is
at rest, then
sitting, then
standing for
initial
evaluation.
Observe skin
color, moisture,
temperature
and capillary
refill time.

Presence of
pallor, cool,
moist skin and
delayed
capillary refill
time may be
due to

Long Term:
After 24 hours
of nursing
intervention
the goal was
partially met

After 24
hours of
nursing
interventio
ns
Patient
maintains BP
within normal
limits

peripheral
vasoconstricti
on
Note
dependent or
general edema.

Provide calm,
restful
surroundings,
minimize
environmental
activity or noise
Maintain
activity
restrictions.

Instruct in
relaxation
techniques, and
guided imagery

May indicate
heart failure,
renal or
vascular
impairment.
Help reduce
sympathetic
stimulation,
promotes
relaxation.

Reduces
physical stress
and tension
that affect
blood pressure
and course of
hypertension.
Can reduce
stressful
stimuli,
produce
calming effect,
thereby
reduce blood
pressure.

Collaborative:
Implement
dietary sodium,
fat, and
cholesterol
restrictions as
indicated.

These
restrictions
can help
manage fluid
retention and
with
associated

the patients
blood pressure
lowered to
130/90
But did not
maintain
within normal
limits.

Administer
medication as
prescribed, noting
response and
watching for side
effects and toxicity.
Clarify with
physician
parameters for
withholding
medications.

hypertensive
response,
which
decrease
cardiac
workload.