Identified Problem: Decreased Cardiac Output

Nursing Diagnosis: Decreased cardiac output related to altered glucose level

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Objective cues: Short term Record intake and Reduced Short term:
 Bipedal edema Objective: output. If patient is cardiac After 4-8
 Hyperglycemia After 4-8 acutely ill, measure output results hours of
(FBS: 21.11 mmol/L) hours of hourly urine output in reduced nursing
 Hypercholesterolemia nursing and note decreases perfusion of intervention
( Cholesterol: 8.84 intervention in output. the kidneys, patient was
the patient with a able to
mmol/L)
will verbalize verbalize
 Fatigue actions and
resulting
understanding
 Activity intolerance precautions to
decrease in
on actions
 Anemia (decreased take for urine output. and
RBC : 2.37/L cardiac limit fluids and precautions to
 Sub segmental disease. sodium as ordered. Fluid take for
atelectasis restriction cardiac
 Chest pain .Long term Closely monitor decreases disease. Goal
 Left ventricular objective: fluid intake extracellular met
cardiomegaly After 3 including IV lines. fluid volume
 Decrease urine days of Maintain fluid and reduces
output nursing restriction if demands of Long term:
intervention ordered. the heart. After 3
the patient days of
will be Examine laboratory Patient may nursing
Subjective cues: compliant on data, especially be receiving intervention
testing blood arterial blood gases patient wasn’t
cardiac
“ Naa juy usahay naa glucose level. and electrolytes, able to test for
glycosides
maglisud kog ginhawa og including potassium FBG level and
and the Hgt for some
magsakit ako dughan” as
potential for financial
verbalized by SO
toxicity is reason. Goal
Monitor laboratory greater with unmet
tests such as
hypokalemia;
complete blood
hypokalemia
count, sodium
is common in
level, and serum
creatinine. heart patients
because of
diuretic use.

Position patient in Monitor

semi-Fowler’s to laboratory
high-Fowler’s. tests such as
complete
blood count,
sodium level,
and serum
creatinine. A
low serum
sodium level
often is
observed with
advanced
heart failure
and can be a
poor
prognostic
sign. Serum
creatinine
levels will
elevate in
patients with
severe heart
failure
because of
decreased
perfusion to
the kidneys.
Creatinine
may also
elevate
because of
ACE
inhibitors.