Jasper Martinez

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Decreased Within 8 hours  Note skin color,  Cold, clammy, and pale After 8 hours of nursing
N/A cardiac output of nursing temperature, and skin is secondary to intervention, goal met, the
related to intervention the moisture. compensatory increase patient was be able to
Objective: hypovolemia patient will be in sympathetic nervous maintain adequate cardiac
 Second and and reduced able to maintain system stimulation and output as evidenced by
third-degree venous return. adequate low cardiac output and strong peripheral pulses,
burns over cardiac output oxygen desaturation. systolic BP within 20 mm Hg
her neck of baseline, HR 60 to 100
 Generalized beats per minute with
paleness regular rhythm, urinary
 Irregular output 30 ml/hr or greater,
rhythm of  Check for any alterations  Decreased cerebral warm and dry skin, and
pulse 120 in level of perfusion and hypoxia normal level of
bpm consciousness. are reflected in consciousness
 BP 104/60 irritability, restlessness,
 RR: 12 cpm and difficulty
(irregular concentrating. Aged
rhythm) patients are particularly
 Unconscious susceptible to reduced
perfusion

 Assess heart rate and  Most patients have

blood pressure compensatory
tachycardia and
significantly low blood
pressure in response to
reduced cardiac output
 Check for peripheral  Weak pulses are present
pulses, including in
capillary refill reduced stroke volume
and cardiac output.
Capillary refill is
sometimes slow or
absent

 Record urine output.

 The renal system
Determine how often
counterbalances low BP
the patient urinates.
by retaining water.
Oliguria is a classic sign
of decreased renal
perfusion

 Note respiratory rate,  Shallow, rapid

rhythm, and breath respirations are
sounds. Identify any characteristics of
presence of paroxysmal decreased cardiac
nocturnal dyspnea output. Crackles indicate
(PND) or orthopnea fluid buildup secondary
to impaired left
ventricular emptying

 An alteration in oxygen
 Assess oxygen
saturation is one of the
saturation with pulse
earliest signs of reduced
oximetry both at rest
cardiac output.
and during and after
 ambulation Hypoxemia is common,
especially with activity

 Check symptoms for  Low cardiac output can

chest pain further decrease
myocardial perfusion,
resulting in chest pain

 Identify emergency plan,  Decreased cardiac

including use of CPR output can be life
threatening