Decreased Cardiac Output

decreased cardiac output nursing diagnosis

Introduction/Pathophysiology [1,2]

Cardiac output (CO), expressed in L/min, is the volume of blood in the heart pump in one minute, depending on the heart’s rate, contractility, preload and afterload. Cardiac output is directly influenced by the heart rate and stroke volume. Regulation of cardiac output includes autonomic nervous system, endocrine and paracrine signaling. Cells, tissues and organs rely on the heart pumping the blood to deliver nutrients. Decreased cardiac output may result in insufficient blood supply and compromise vital reactions. This can result in transition towards anaerobic metabolic pathways which lead to production of lactic acid, reduced cellular pH, enzyme denaturation, and altered membrane potential. If not addressed, decreased cardiac output can lead to tissue and organ damage. Most common diagnoses associated with decreased cardiac output is heart failure. Heart failure (HF) is defined as failure of either the left and/or right chambers of the heart resulting in insufficient output to meet tissue needs resulting in pulmonary and systemic vascular congestion. In addition, blood pooling in the ventricles can increase the risk for stroke and pulmonary embolism. Decreased cardiac output nursing care plan and nursing interventions for decreased cardiac output are crucial steps to prevent possible life-threatening complications.

Causes[1]

Impaired cardiac function and decreased cardiac output can be caused by:

  • coronary disease
  • hypertension
  • congenital problems
  • tamponade
  • medications such as vasopressor and calcium channel blockers
  • pericardial effusions
  • emboli
  • congestive heart failure
  • shock
  • cardiac arrhythmias/dysrhythmias
  • genetic diseases
  • structural abnormalities
  •  myocardial ischemia and myocardial infarction

Symptoms[1]

Subjective (client may report)

  • fatigue
  •  exhaustion progressing throughout the day
  •  exercise intolerance
  • insomnia
  • chest pain/pressure with activity
  •  dyspnea at rest or with exertion

Objective[1]:

  • Increased heart rate
  • Altered myocardial contractility
  • inotropic changes
  • Diagnosis for Atrial Fibrillation
  • History of decreased cardiac output nursing diagnosis
  • irregular heart rate
  • Changes in rhythm and electrical conduction
  • Cardiac dysrhythmia
  • Structural heart changes
    • valvular defects
    • ventricular aneurysm
  • Jugular vein distention
  • Extra heart sounds
  • Decreased urine output
  • Diminished peripheral pulses
  • Cool, ashy skin; diaphoresis
  • Wheezes
  • Tachypnea
  • Nail beds pale or cyanotic, with slow capillary refill
  • Orthopnea
  • Crackles
  • Liver engorgement
  • Edema
  • Lower extremity swelling
  • Mental status change
  • Cough
    • Dry/hacking/nonproductive
    • gurgling with/without sputum
  • Restlessness, anxiety
  • Lethargy
  • Vital signs change with activity
  • Breath sounds diminished, bibasilar crackles

Risk factors[1]:

  • History of hypertension
  • Recent/acute MI
  • Previous episodes of HF
  • Valvular heart disease, cardiac surgery
  • Endocarditis
  • Systemic lupus erythematosus (SLE)
  • Anemia
  • Septic shock
  • Swelling of feet, legs, abdomen,
  • Diet high in salt/processed foods, fat, sugar, and caffeine
  • Smoking

Nursing interventions for decreased cardiac output[1]

Assessment[1]

Collect client history, including risk factors and symptoms (objective and subjective data)

Cardiac function

  • Increased HR
  • Altered myocardial contractility
  • Diagnosis for Atrial Fibrillation
  • Structural changes
  • Jugular vein distention
  • Extra heart sounds
  • Diminished peripheral pulses

Neurologic/Sensory function

  • Mental status change
  • Restlessness
  • Anxiety
  • Lethargy

Respiratory function

  • Breath sounds
  • Wheezing
  • Cough
  • Tachypnea
  • Orthopnea

Visual appearance/labs

  • Skin (cool/ashy)
  • Nail beds
  • Edema
  • Decrease Urine Output
  • Lower extremity swelling

Decreased Cardiac Output Nursing diagnosis[1]

Diagnostic testRationale
ECGVentricular or atrial hypertrophy, axis deviation, ischemia, and damage patterns may be present. Dysrhythmias, e.g.,tachycardia, atrial fibrillation, conduction delays, especially left bundle branch block, frequent premature ventricular con-tractions (PVCs) may be present. Persistent ST-T segment abnormalities and decreased QRS amplitude may be present.
Chest X-rayMay show enlarged cardiac shadow, reflecting chamber dilation/hypertrophy, or changes in blood vessels, reflecting increased pulmonary pressure. Abnormal contour, e.g., bulging of left cardiac border, may suggest ventricular aneurysm.
Sonograms echocardiogram

Doppler and transesophageal echocardiogram

May reveal enlarged chamber dimensions, alterations in valvular function/structure, the degrees of ventricular dilation and dysfunction.
Heart scanMeasures cardiac volume during both systole and diastole, measures ejection fraction, and estimates wall motion.
Exercise or pharmacological stress myocardial perfusionDetermines presence of myocardial ischemia and wall motion abnormalities.

Positron emission tomography (PET) scan. Sensitive test for evaluation of myocardial ischemia/detecting viable myocardium.

Cardiac catheterizationAbnormal pressures are indicative and help differentiate right- versus left-sided heart failure, as well as valve stenosis or insufficiency. Also assesses patency of coronary arteries. Contrast injected into the ventricles reveals ab-normal size and ejection fraction/altered contractility. Transvenous endomyocardial biopsy may be useful in some clients to determine the underlying disorder, such as myocarditis or amyloidosis.
Liver enzymesElevated in liver congestion/failure
Digoxin and other cardiac drug levelsDetermine therapeutic range and correlate with client response.
Bleeding and clotting timesMay be altered because of fluid shifts/decreased renal function, diuretic therapy.
Electrolytes:May be altered because of fluid shifts/decreased renal function, diuretic therapy
Pulse oximetryOxygen saturation may be low, especially when acute HF is imposed on chronic obstructive pulmonary disease (COPD) or chronic HF.
Arterial blood gases (ABGs)Left ventricular failure is characterized by mild respiratory alkalosis (early) or hypoxemia with an increased PCO2(late).
BUN/creatinineElevated BUN suggests decreased renal perfusion. Elevation of both BUN and creatinine is indicative of renal failure.
Serum albumin/transferrin:May be decreased as a result of reduced protein intake or reduced protein synthesis in congested liver.
Thyroid studiesIncreased thyroid activity suggests thyroid hyperactivity as precipitator of HF.
Complete blood count (CBC)May reveal anemia, polycythemia, or dilutional changes indicating water retention. Levels of white blood cells (WBCs) may be elevated, reflecting recent/acute MI, pericarditis, or other inflammatory or infectious states.
ESR:May be elevated, indicating acute inflammatory reaction

Planning[1]

  • Improve myocardial contractility/systemic perfusion
  • Reduce fluid volume overload
  • Prevent complications
  • Familiarize other providers with the decreased cardiac output nursing care plan to ensure proper collaboration
  • Provide information about disease/prognosis, therapy needs, and prevention of

Nursing actions[1]

Perform
  • Auscultate apical pulses
  • Assess heart rate and rhythm
  • Document dysrhythmias
  • Palpate peripheral pulses
  • Skin inspection for pallor, cyanosis
  • assist with physical care
  • Elevate legs, avoiding pressure under the knee
  • Check for calf tenderness
Provide
  • Quiet environment
  • Help prevent stress
Administer
  • Supplemental oxygen
  • IV fluids/electrolytes
  • Medications as indicated (diuretics, vasodilators-nitrates, arteriodilators-hydralazine, combination drugs-prazosin, ACE inhibitors, digoxin, inotropic agents, beta blockers, morphine, anxiety agents, sedatives, anticoagulants)
Monitor
  • Heart sounds
  • Blood pressure
  • Heart rate
  • Urine Output
Encourage
  • Rest
  • Active/passive exercises
  • Verbalization of clients’ concerns and provide the client with decision-making opportunities

Goals and Outcomes[1]

  • Cardiac output adequate for individual needs
  • Complications prevented/resolved
  • Optimum level of activity/functioning attained
  • Disease process/prognosis and therapeutic regimen understood by
  • Plan in place to meet needs after discharge
  • Provide at home care plan decreased cardiac output

Post intervention evaluation/monitoring[1]

Monitor[1]

  • Cardiac rate and BP, ECG, chest x-ray, central venous pressure if available
  • Urine output and dark/concentrated urine
  • Mental status and changes in sensorium
  • Check for calf tenderness
  • Inspect skin
  • Lab results: BUN, creatinine, AST, LDH, PT, aPTT

Future goals [1]

  • Dysrhythmia controlled or absent
  • Pulse oximetry within acceptable range/ free of signs of respiratory distress
  • Client meets all self-care needs
    • Care plan decreased cardiac output shared with primary care provider
  • Client demonstrates increase in activity tolerance

Prevention [1]

  • Educate about the diagnosis, symptoms and treatment
    • Provide decreased cardiac output nursing care plan adjusted for home care
  • Promote healthy lifestyle and diet
  • Promote healthy lifestyle and diet
  • Provide plan to decrease stress and prevent anxiety

Supplemental material

Client case

Client presents to the ER with the chief complaint of fatigue and shortness of breath when engaging in mild physical activity. Client has also noticed a recent weight gain and swelling in ankles. Client’s current blood pressure is 146/80 and heartbeat is 70 bpm. Client has a history of atrial fibrillation, hypertension, dyslipidemia and type 2 diabetes.

Questions:

Based on the client case, what are the symptoms predictive of heart failure?

Answer: shortness of breath, fatigue, edema

Changes in what lab value is indicative of renal failure in clients with decreased cardiac output?

  • a. AST
  • b. BUN
  • c. Troponin
  • d. VHDL

What chronic medications should be generally avoided in clients with known diagnosis of heart failure?

  • a. ACE inhibitors
  • b. Beta blockers
  • c. Calcium channel blocker
  • d. morphine

Which exam can measure cardiac volume during systole and diastole?

  • a. Chest X-ray
  • b. ECG
  • c. Heart scan
  • d. Sonogram

Units that represent Cardiac Output are:

  • a. L
  • b. L/min
  • c. m3
  • d. min

References

  1. Vincent JL. Understanding cardiac output. Crit Care. 2008;12(4):174. doi:10.1186/cc6975
  2. King J, Lowery DR. Physiology, Cardiac Output. In: StatPearls. Treasure Island (FL): StatPearls Publishing; September 15, 2020.