Nurse's Pocket Guide

of extremities, and progressive shortness of breath to assess
for signs of poor ventricular function and/or impending
cardiac failure.
• Determine vital signs/hemodynamic parameters including
cognitive status. Note vital sign response to activity/procedures
and time required to return to baseline. Provides baseline
for comparison to follow trends and evaluate response to
interventions.
• Review signs of impending failure/shock, noting decreased
cognition and unstable/low blood pressure/invasive hemodynamic
parameters; tachypnea; labored respirations; changes
in breath sounds(e.g., crackles, wheezing); distant or altered
heart sounds (e.g., murmurs, dysrythmias); and reduced urinary
output. Early detection of changes in these parameters
promote timely intervention to limit degree of cardiac dysfunction.
• Note presence of pulsus paradoxus, especially in the presence
of distant heart sounds, suggesting cardiac tamponade.
• Review diagnostic studies (e.g., cardiac stress testing, ECG,
scans, echocardiogram, heart catheterization, chest x-rays,
electrolytes, CBC). Helps determine underlying cause.
NURSING PRIORITY NO. 3.To minimize/correct causative factors,
maximize cardiac output:
ACUTE PHASE
• Keep client on bed or chair rest in position of comfort. In congestive
state, semi-Fowler’s position is preferred. May raise
legs 20–30 degrees in shock situation. Decreases oxygen consumption
and risk of decompensation.
• Administer high-flow oxygen via mask or ventilator, as indicated,
to increase oxygen available for cardiac function/
tissue perfusion.
• Monitor vital signs frequently to note response to activities/interventions.
• Perform periodic hemodynamic measurements, as indicated
(e.g., arterial, CVP, pulmonary, and left atrial pressures;
cardiac output).
• Monitor cardiac rhythm continuously to note effectiveness
of medications and/or assistive devices, such as implanted
pacemaker/defibrillator.
• Administer blood/fluid replacement, antibiotics, diuretics,
inotropic drugs, antidysrhythmics, steroids, vasopressors,
and/or dilators, as indicated. Evaluate response to determine
therapeutic, adverse, or toxic effects of therapy.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 147
decreased CARDIAC OUTPUT