Dco Careplan

Morgan Clark Date: 11/14/2016
Med/Surg Nursing Diagnosis: Decreased cardiac output r/t inadequate pumping and filling of the heart secondary to CHF aeb BNP 447, 2
edema BL calves, and acute respiratiory failure.
Long Term Goal: Pt will have increased cardiac output
Outcome Criteria Priority Intervention Rationale
1. Assess VS and O2sat q4h

1. Pt VS will be BP 100-130/60- (assessment)
80, HR 60-100, RR 12-20, 1. Pt is a 71 y/o female admitted with acute respiratory failure from combination of acute
O2sat 95-100%, TPR 97.8- diastolic CHF associated with acute exacerbation of COPD. PMH of HTN, Type 2
Diabetes, chronic atrial fibrillation, morbid obesity, BL PE, and DVT of RLE. CXR
100.4F oral as assessed q4h indicating pleural effusions and atelectasis. Pt was admitted to the ER being SOB and in
acute respiratory failure. Recent EKG showed an uncontrolled, irregular rate and rhythm
also known as atrial fibrillation. Vital signs are an important measure not only to monitor
this condition, but for potential complications that can occur, such as a stroke, pulmonary
embolus, or HF. The atria failing to pump all of the blood into the ventricles will not only
cause a decrease in CO, but pooling in the atria, increasing a risk for a thrombus. The left
ventricle thickening shown in pt recent echo shows a further decrease in CO. As a result,
the pt exhibiting complications from a thrombus will present with increased respirations
and heart rate, decreased blood pressure and oxygen, or in this patients case, similar
indications of heart failure, but with increasing pulmonary edema and risk for another
acute episode of respiratiory failure. Lewis 769
2. Pt is a 71 y/o female admitted with acute respiratory failure from combination of acute
2. Pt lungs will remain free of 2. Assess lung sounds q4h diastolic CHF associated with acute exacerbation of COPD. PMH of HTN, Type 2
rhonchi, crackles, and wheezes (assessment) Diabetes, chronic atrial fibrillation, morbid obesity, BL PE, and DVT of RLE. CXR
indicating pleural effusions and atelectasis. Pt was admitted to the ER being SOB and in
as assessed q4h acute respiratory failure. Auscultating lung sounds can identify an abnormality in the
movement of air, classifying them as adventitious. When HF is present, rhonchi, wheezes
and crackles are commonly heard over the infected area due an increase in blood flow
and vascular permeability. HF from the LV will increase pulmonary pressure that causes
fluid leakage from the pulmonary capillary bed into the interstitium and then the alveoli.
This will manifest as pulmonary congestion and edema that can be auscultated in the
lungs. Pt lung sounds were clear, but dimished, indicating that there could be fluid buildup
in the lung tissue that could progress to crackles. Making frequent assessments will catch
a change in status early to implement further interventions to prevent respiratory failure,
and prevent worsening HF. Lewis 487-490
3. Pt will remain free of chest 3. Assess pain qh
pain as assessed qh (assessment)
diastolic CHF associated with acute exacerbation of COPD. PMH of HTN, Type 2
also known as atrial fibrillation. Atrial fibrillation increases the pt risk of producing a
thrombus from blood pooling in the atria from disorganized atrial electrical activity,
resulting in ineffective atrial contractions that decreases CO. An embolized clot may
develop and move to the brain to cause a stroke, or manifest a blockage in the pulmonary
arteries, also known as a PE. The embolus will travel with blood flow through small blood
vessels until it lodges and obstructs perfusion of the alveoli. The pt is at further risk for an
embolized thrombus because of previous PE and DVT that occured during this year.
Assessing the client for pain, especially in the chest, can give an indication that a
complication from A.Fib is occurring. Dyspnea, along with tachypnea, wheezing, cough,
along with sudden change in mental status can be a result of hypoxemia. Chest pain can
also be an indication of worsening HF because of decreased CO that increases the
response to increased oxygen demand. Lewis 550-555 & 796-797
4. Pt will have reduction of LE 4. Assess edema q4h

edema from 2+ pitting to 1+ (assessment)
pitting within 24h
also known as atrial fibrillation. Edema is a common sign of HF and is caused by a back
up of blood into the venus circulation. The venous congestion pushes fluid into the
peripherial tissue causing the swelling. The pt had 2+ pitting edema in LE indicating a
large amount of fluid had been retained and not excreted. The increase in the pressure
increases the workload on the heart, further decreasing CO. Assessing edema gives an
idea of the degree of HF the pt is experiencing as well as a tool to evaluate how effective
diuretic therapy is at reducing the amount of fluid in the extracellular spaces. Lewis 771 &
776
5. Monitor pedal pulses and
cap refill q4h (monitor)
5. Pt PP will be 2+ and have a
cap refill <3seconds in all diastolic CHF associated with acute exacerbation of COPD. PMH of HTN, Type 2
extremities upon palpation q4h Diabetes, chronic atrial fibrillation, morbid obesity, BL PE, and DVT of RLE. CXR
also known as atrial fibrillation. HTN is a primary risk factor for the pt developing HF.
Adequate arterial flow to the extremities is indicated by a cap refill that is < 3 sec and
brisk, a cap refill greater than that indicates decreased peripheral perfusion and CO. The
strength or amplitude of a pulse reflects the volume of blood ejected against the arterial
wall with each heart contraction and condition of the arterial vascular system leading to
the pulse site. Coagulation disorders, for example, will diminish pulse strength from a clot
causing mechanical obstruction to blood flow. It is important to assess pulse strength and
amplitude to determine cardiovascular health, especially in this pt who is already at
increased risk for blood clots from PMH and decreased CO from atrial fibrillation.
Catching any changes early is critical in the overall prognosis of the pt with a
compromised cardiovascular system. Lewis 766-769
6. Pt I&O will be within 200ml 6. Monitor I&O q4h diastolic CHF associated with acute exacerbation of COPD. PMH of HTN, Type 2
of each other qs (monitor) Diabetes, chronic atrial fibrillation, morbid obesity, BL PE, and DVT of RLE. CXR
indicating pleural effusions and atelectasis, resulting from the increasing pressure from
the pleural capillaries. Pt was admitted to the ER being SOB and in acute respiratory
failure with acute dehydration with elevated BUN. Recent EKG showed an uncontrolled,
irregular rate and rhythm also known as atrial fibrillation. This can lead to decreased CO,
also decreasing renal perfusion. In response, the kidneys will hold onto fluid in response
to low CO by controlling Na+ excretion. Adequate CO is indicated as kidneys are
adequately perfused, producing at least 30ml/hr). Monitoring output while the patient is in
signs of volume overload can indicate if diuretic therapy is working efficiently or if therapy
needs to be adjusted. Lewis 776 P&P 885-887
7. Monitor electrolytes as
7. Pt K+ will be 3.5-5.2, Na+ ordered daily (dependent)
136-145, calcium 8.5-10.8, and 7. Pt is a 71 y/o female admitted with acute respiratory failure from combination of acute
magnesium 1.7-2.6 when diastolic CHF associated with acute exacerbation of COPD. PMH of HTN, Type 2
drawn daily. Diabetes, chronic atrial fibrillation, morbid obesity, BL PE, and DVT of RLE. CXR
failure with acute dehydration with elevated BUN. Electrolyte disturbances can cause
further dysrhythmia to someone who already has Atrial fibrillation, and if not treated, can
be life-threatening. As diminished CO reduce kidney perfusion to activate the RAAS,
aldosterone on the kidneys causes ECV excess. Diuretic therapy, Lasix is used to reduce
the fluid and increases pt risk for hypokalemia as this pt developed when admitted in the
ER. With dosage adjustment, the electrolyte levels returned to therapeutic range and
remained in a safe range for the pt. Lewis 790 P&P 888-890
8. Pt O2sat will remain within 8. Administer O2 2-6L/min diastolic CHF associated with acute exacerbation of COPD. PMH of HTN, Type 2
95-100% at all times. NC continuous as ordered Diabetes, chronic atrial fibrillation, morbid obesity, BL PE, and DVT of RLE. CXR
(dependent) acute respiratory failure. To maintain adequate peripheral and cerebral perfusion, oxygen
saturation should be 95% or higher continuously. A dysrhythmia like atrial fibrillation
decreases CO, decreasing the amount of oxygen being carried to the body resulting in
insufficient oxygen perfusion to tissue. Left-sided HF increases pulmonary pressure that
causes fluid leakage from the pulmonary capillary bed into the interstitium and then the
alveoli. This will manifest as pulmonary congestion and edema to decrease gas exchange
and total lung volume available for oxygen intake. When this occurs, room air may not be
a high enough concentration of oxygen suitable to adequately perfuse the body tissues
requiring supplemental oxygen therapy. Oxygen therapy is evaluated by pt response of
decrease in fatigue, ability to take a deep breath, and O2sat being between 95-100%.
Adequate oxygen intake decreases the workload on the heart because the heart muscle
isn't triggered to try and overcompensate for a lack of O2 intake. Lewis 768-772
9. Administer furosemide
9. Pt edema in LE will reduce
from 2+ pitting to at least 1+ 60mg po BID as ordered
pitting within 24hr of (dependent) diastolic CHF associated with acute exacerbation of COPD. PMH of HTN, Type 2
furosemide therapy. Diabetes, chronic atrial fibrillation, morbid obesity, BL PE, and DVT of RLE. CXR
failure with acute dehydration with elevated BUN. Pt presented with 2+ pitting edema
throughout LE. Furosemide is a loop diuretic that acts to reduce excess fluid in the body.
Diuretics act to decrease sodium reabsorption at various sites within the nephrons,
thereby enhancing sodium and water loss. Decreasing intravascular volume with the use
of diuretics reduces venous return and subsequently the volume returning to the LV.
Allowing LV to contract more efficiently. CO is increased, pulmonary vascular pressures
are decreased, and gas exchange is improved. Lewis 773-774
10. Administer diltiazem

10. Pt will maintain ventricular HCL 180mg po qday as
rate between 60-100bpms ordered (dependent)
during diltiazem HCL therapy.
also known as atrial fibrillation. Before admission, this pt was on diltiazem HCL at home to
control the ventricular rate of her A.Fib. Diltiazem inhibits transport of calcium into
myocardial and cascular smooth muscle cells, resulting in the inhibition of excitation-
contraction coupling and subsequent contraction to reduce HR and decrease myocardial
oxygen consumption and increase CO. Ventricular rate control is a priority for patients
with atrial fibrillation because atrial fibrillation results in a decrease in CO because of
ineffective atrial contractions (loss of atrial kick) and/or a rapid ventricular response.
Thrombi (clots) form in the atria because of blood stasis, which can embolize and move to
other parts of the body, which this pt is at an increased risk for blood clots from previous
history of PE and DVT. Lewis 796
11. Obtain order for BNP
11. Pt BNP will decrease draw now (independent)
towards 400 when drawn now.
also known as atrial fibrillation. B-type natriuretic peptide (BNP) is secreted by the
ventricles and is the marker of choice for distinguishing a cardiac or respiratory cause of
dyspnea. When diastolic blood pressure increases (heart failure), BNP is released in
response to increased blood volume in the heart. BNP levels correlate positively with the
degree of left ventricular failure because it is released during myocardial damage caused
by stretching. BNP is a natural antagonist to the RAAS system as it will promote excretion
of sodium and water, resulting in a decrease in blood volume and BP. Decreasing
workload on the heart muscle to maintain adequate CO. A level >100 is an indication of
heart failure, as this pts was 447. These levels should be monitored daily to implement
measures to prevent further myocardial damage. Lewis 290, 698, 768
12. Pt will correctly use ISP 10x 12. Encourage ISP qh while
qh while awake. awake (independent) 12. Pt is a 71 y/o female admitted with acute respiratory failure from combination of acute
also known as atrial fibrillation. Use of ISP will promote alveolar ventilation, by inhaling
slowly and deeply and holding the inhaled breath for 3-5 seconds before exhaling slowly
increases lung volume. Completing this 10 times will help to reduce the pts collapse of
the alveoli, promoting a cough to assist with lung fluid mobilization. This will help the pt to
facilitate adequate lung expansion, and expell the fluid build up and reverse atelectasis,
allowing for adequate O2 intake and perfusion to reduce oxygen demand on the heart.
Lewis 526-528
13. Teach cardiac diet qs
13. Pt will correctly list at least (teaching)
3 high sodium foods to avoid 13. Pt is a 71 y/o female admitted with acute respiratory failure from combination of acute
and 3 low sodium foods to diastolic CHF associated with acute exacerbation of COPD. PMH of HTN, Type 2
include in diet prior to dc. indicating pleural effusions and atelectasis. Pt was admitted to the ER being SOB and in
also known as atrial fibrillation. Poor adherence to a low-sodium diet and failure to take
prescribed medications as directed are the two most common reasons for readmissions
of HF patients to the hospital. Diet teaching and weight management are essential to the
patient's control of chronic HF. The edema associated with chronic HF is often treated by
dietary restriction of sodium. General Principles include; do not add salt or seasonings
containing sodium when preparing foods, do not use salt at the table, avoid high-sodium
foods (e.g., canned soups, processed meats, cheese, frozen meals), limit milk products to
2 cups daily. On this diet, processed meats, cheese, bread, cereals, canned soups, and
canned vegetables must be limited. Lewis 777-779
14. pt will ambulate at least 14. Ambulate at least twice diastolic CHF associated with acute exacerbation of COPD. PMH of HTN, Type 2
50ft in hall at least two times qs (independent) Diabetes, chronic atrial fibrillation, morbid obesity, BL PE, and DVT of RLE. CXR
qs acute respiratory failure. Pt activity level is sedentary. Exercise is an important tool in
treating HF because it can alleviate some of the symptoms associated with decreased CO
like fluid retention and edema. Ambulating down the hallway a few times a day can
dramatically change how the pt feels with more blood pumping oxygen to the body tissue.
It is important to start out slow and work up to increased distances with plenty of rest
periods to reduce the risk of overworking the heart and putting too much oxygen demand
on the heart muscle. Lewis 782
15. Pt will schedule an 15. Refer to cardiac 15.Pt is a 71 y/o female admitted with acute respiratory failure from combination of acute
appointment with cardiac rehabilitation program prior Diabetes, chronic atrial fibrillation, morbid obesity, BL PE, and DVT of RLE. CXR
rehabilitation team prior to dc. to dc (collaboration) indicating pleural effusions and atelectasis. Pt was admitted to the ER being SOB and in
also known as atrial fibrillation. Pt activity level is sedentary. It is important that the pt
understands the reasons why exercise is still an important part of managing their HF and
improving the heart muscle. After the pt is dc, the rehabilitation should monitor the pt for
2-12 wks in an outpatient facility to safely increase activity level under the supervision of a
cardiac rehabilitation team with ECG monitoring, making suggestions for physical activity
at home. Lewis 775 & 782
ndary to CHF aeb BNP 447, 2+ pitting
Evaluation
1. Met: pt BP 102/58, HR 62,

RR 16, O2sat 96% 2L/min O2
NC, TPR 97.0%F oral.
2. Met:pt lung sounds

diminished but free of rhonchi,
crackles, or wheezes in all lung
fields.
3. Met: pt pain remained 0/10
throughout shift.
4. Unmet: Pt edema in LE
remained at 2+ pitting
throughout shift.
5. Partially met: Pt cap refill
<3seconds in all extremities
but PP remained at 1+
throughout shift.
6. Unmet: Pt output could not

be determined because of
being incontinent both voids
during shift. Pt intake was
610ml.
7. Met: pt K+ 4.5, Na+ 138,
Calcium 8.5, and magnesium
2.0 on last lab draw prior to dc.
8. Met: pt O2sat remained

between 96-100% on 2L/min
O2 NC during shift.
9. Unmet: pt edema remained
at 2+ pitting in LE during shift.
10. Met: pt HR remained

within 60-100bpms during
shift.
11. Unmet: BNP was not re-
ordered prior to pt dc.
12. Unmet: Pt did not use ISP

prior to dc.
13. Met: Pt correctly listed
high sodium foods to avoid and
low sodium foods to implement
in diet.
14. Unmet: pt refused to

ambulate during shift.
15. Unmet: referall was not

made, pt did not want rehab.

Dco Careplan

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Morgan Clark Date: 11/14/2016

1. Assess VS and O2sat q4h

4. Pt will have reduction of LE 4. Assess edema q4h

10. Administer diltiazem

1. Met: pt BP 102/58, HR 62,

2. Met:pt lung sounds

6. Unmet: Pt output could not

8. Met: pt O2sat remained

10. Met: pt HR remained

12. Unmet: Pt did not use ISP

14. Unmet: pt refused to

15. Unmet: referall was not

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