Ms. Sandler, 27 years
old, a certified public accountant. She has irregular menstruation flow. One
day she experienced 2 weeks menstrual bleeding which she thought it was a bad
sign so she decided to go to see a doctor. She never experience bleeding a lot that
she could soak 6 pads every day and she said to her doctor that she felt having
palpitations. Below is a sample of decreased cardiac output nursing care plan
of Ms. Sandler.
ASSESSMENT
Subjective:
"I feel that I'm having palpitations right now," as verbalized by the patient.
Objectives:
I observed from the
patient that she has distended neck vein and facial edema. She also positive in
prolonged capillary refill as I press his/her fingertip (prolonged capillary
refill is when it takes too much time before your fingertip return to its normal
color after you press it. The patient is restlessness as she can't stay still
and find his/her comfort.
Vital signs are taken
and noted as follows: Body temperature is 36.8 degrees Celsius, blood pressure
is 110/70 mmHg, respiratory rate is 20 cycles per minute, and pulse rate is 128
beats per minute. There's slightly above normal in her body temperature while
blood pressure and respiratory rate are in normal range. But the patient is in
tachycardia as her pulse rate exceeds the 80-100 beats per minute normal range.
DIAGNOSIS
Decreased cardiac output
related to palpitations as evidenced by altered heart rate (tachycardia) and
distended neck vein.
PLANNING
After 4 hours of nursing
intervention, the patient's cardiac output will be normalized and her palpitations
will be gone.
INTERVENTION
- Before you start any
nursing interventions, determine first Ms. Sandler's vital signs and her
hemodynamic parameters including her cognitive status. The initial vital signs
taken will be the baseline for comparison to follow trends and evaluate her
response to interventions. Note vital signs responses to activity procedures
and time required to return to baseline.
- You must review her
diagnostic and laboratory data such as cardiac makers, complete blood count and
electrolytes. These will help determine the underlying causes of decreased
in cardiac output. After these, perform to Ms. Sandler the periodic hemodynamic
measurements as indicated such as arterial pressures and cardiac output and
monitor cardiac rhythm continuously to note effectiveness of medications
and assistive devices such as implanted pacemaker of defibrillator.
Maintain patency of invasive intravascular monitoring and infusion lines.
Tape the connections to prevent air embolus and exsanguination. Also assess the
patient's urine periodically; weigh daily and note her total fluid balance.
- You may administer
high-flow oxygen via mask or ventilator as indicated because this can increase
her oxygen available for cardiac function and tissue perfusion. In addition,
depending on Ms. Sandler as indicated, restrict or increase fluids. You must
change linens routinely and administer antipyretics as indicated, to maintain
body temperature in near-normal range.
EVALUATION
After 4 hours of nursing intervention, the patient's cardiac output normalized and her palpitations are gone.
For more samples of nursing care plan you are free to check it out in our NCP LIST page.
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