Effective nursing care and interventions play a vital role in optimizing cardiac function, ensuring hemodynamic stability, and preventing potential complications associated with decreased cardiac output, including organ failure, inadequate tissue perfusion, and reduced oxygenation. This comprehensive guide equips healthcare professionals with the knowledge and skills necessary to provide optimal cardiac support through thorough nursing assessments, accurate nursing diagnoses, well-defined goals, and evidence-based interventions.
Cardiac output is the amount of blood pumped by the heart per minute. It is the product of the heart rate, which is the number of beats per minute, and the stroke volume, which is the amount pumped per beat (cardiac output = heart rate x stroke volume). The cardiac output is usually expressed in liters/minute (L/min).
The normal cardiac output of a healthy adult is generally considered to be between four to six liters per minute (L/min) at rest (King and Lowery, 2022). However, it is important to note that the normal range can vary depending on various factors such as age, size, and activity level. For example, elite athletes have a cardiac output of more than 35 L/min during exercise.
Changes in heart rate are due to the inhibition or stimulation of the sinoatrial node (SA) node mediated by the parasympathetic and sympathetic divisions of the autonomic nervous system. Additionally, the heart rate is affected by the central nervous system and baroreceptor activity. Baroreceptors are specialized nerve cells located in the aortic arch and in both right and left internal carotid arteries and are sensitive to changes in blood pressure. Compensatory mechanisms that occur during BP changes include:
Stroke volume (SV) is determined by three of the following factors:
There are several methods that can be used to calculate and measure cardiac output. When choosing the technique, several factors need to be taken into account, including their invasiveness, measurement performance, ability to provide real-time continuous cardiac output readings, ability to calibrate the readings to a reference method, and the ability to provide additional hemodynamic variables.
A decrease in cardiac output occurs when the blood pumped by the heart does not meet the metabolic demands of the body. Several cardiovascular diseases such as myocardial infarction, heart failure, dysrhythmias, and other problems in fluid volume, can cause a decrease in cardiac output.
Conditions like myocardial infarction, hypertension, valvular heart disease, congenital heart disease, cardiomyopathy, heart failure, pulmonary disease, arrhythmias, drug effects, fluid overload, decreased fluid volume, and electrolyte imbalance are common causes of decreased cardiac output. Additionally, here are some related factors that may be related to a decrease in cardiac output:
Cardiovascular diseases and conditions that lead to decreased cardiac output can pose significant challenges to client health and well-being. The nursing management of a client diagnosed with a condition that causes a decrease in cardiac output is essential in promoting optimal client outcomes and enhancing their quality of life. The nursing care plan will focus on different aspects of client care, including optimizing cardiac function, managing symptoms, promoting client and caregiver education, and preventing complications.
The following are the nursing priorities for clients with decreased cardiac output:
Assessment is necessary to distinguish possible problems that may have led to decreased cardiac output and name any episode during nursing care. A decrease in cardiac output is characterized by the following subjective and objective manifestations:
By conducting a thorough nursing assessment and formulating a nursing diagnosis, the nurse can develop an individualized care plan that addresses the specific issues of the client. This ensures that the care provided is tailored to meet the needs of the client and their families. It also allows the nurse to focus on specific areas of concern and implement targeted interventions to address identified issues. A well-formulated nursing diagnosis guides the development of a comprehensive nursing care plan that results in improved client outcomes.
The following are the common goals and expected outcomes for the nursing diagnosis of decreased cardiac output:
Therapeutic nursing interventions and nursing actions for a client with decreased cardiac output include:
Accurate assessment of the client can lead to early detection of complications. By identifying potential risks and complications associated with decreased cardiac output, the nurse can take proactive measures to prevent or manage these issues.
Assess heart rate and rhythm.
Compensatory tachycardia is a common response for clients with significantly low blood pressure to reduce cardiac output. Initially, this compensatory response has a favorable effect on cardiac output but can be harmful when it becomes persistent. For the initial cardiac examination, the heart rate should be counted by auscultating the apical pulse, located at the point of maximal impulse (PMI), for a full minute while simultaneously palpating the radial pulse. Dysrhythmias may be noted, and these may stimulate the ventricles to contract prematurely before diastole is finished.
Auscultate the blood pressure and note for orthostatic hypotension.
Orthostatic hypotension is a sustained decrease of at least 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP within three minutes of moving from a lying or sitting position. In cerebrovascular disease, this is most often due to a significant reduction in preload, which compromises the cardiac output. Position the client first supine for ten minutes before taking the initial BP and heart rate measurements. Then, reposition the client to a sitting position with legs dangling for two minutes, then reassess both BP and heart rate.
Check for peripheral pulses.
Weak pulses are present in reduced stroke volume and cardiac output. To assess peripheral circulation, the nurse locates and evaluates all arterial pulses, which can be detected over the right and left temporal, common carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial arteries. Light palpation is essential. Arteries in the extremities are often palpated simultaneously to facilitate comparison of quality.
Assess for jugular vein pulsations.
Clients who have normal blood volume have visible jugular veins while lying in a supine position with the head of the bed elevated at 30°. If the client’s jugular veins are obviously distended with the head of the bed elevated at 45° to 90°, it suggests an increase in CVP. this is associated with right-sided heart failure.
Perform capillary refill test (CRT).
Capillary refill is sometimes slow or absent. Prolonged capillary refill time indicates inadequate arterial perfusion to the extremities. The nurse compresses the nail bed briefly to occlude perfusion and the nail bed blanches, the nurse then releases pressure and determines the time it takes to restore perfusion. Normal reperfusion should occur within two seconds. Clinical decisions should not be based on CRT measurement alone.
Auscultate heart sounds for gallops (S3, S4); auscultate breath sounds.
The new onset of a gallop rhythm, tachycardia, and fine crackles in lung bases can indicate the onset of heart failure. If the client develops pulmonary edema, there will be coarse crackles on inspiration and severe dyspnea. S3 indicates reduced left ventricular ejection and is a class sign of left ventricular failure. S4 occurs with reduced compliance of the left ventricle, which impairs diastolic filling. Gallop sounds are very low-frequency sounds and are heard with the bell of the stethoscope placed very lightly against the chest.
For more interventions and comprehensive care planning, please visit 18 Heart Failure Nursing Care Plans.
Note skin color, temperature, and moisture.
The nurse assesses the skin color, temperature, and texture for acute and chronic problems with arterial or venous circulation. Cool skin and diaphoresis suggest low cardiac output causing sympathetic nervous system stimulation with resultant vasoconstriction. This may be associated with cardiogenic shock or acute myocardial infarction.
Check for any alterations in the level of consciousness.
Decreased cerebral perfusion and hypoxia are reflected in irritability, restlessness, and difficulty concentrating. Older adults are particularly susceptible to reduced cerebral perfusion. Changes in the level of consciousness and mental status may be attributed to inadequate perfusion of the brain from a compromised cardiac output or stroke. The client may also experience signs of distress, which include shortness of breath or anxiety.
Note respiratory rate, rhythm, and breath sounds.
Shallow, rapid respirations are characteristics of decreased cardiac output. Crackles indicate fluid buildup secondary to impaired left ventricular emptying. The client may experience debilitating symptoms at rest and with exertion, as low measured preload often leads to decreased cardiac output and ultimately dyspnea. Dyspnea in chronic low-preload states can be exacerbated by acute hypovolemia from reduced fluid intake, excessive perspiration, diarrhea, hemorrhage, and impairment of regulatory mechanisms (Tooba et al., 2020).
Identify any presence of paroxysmal nocturnal dyspnea (PND), or orthopnea.
PND is closely related to decreased cardiac output. While sleeping at night, peripheral edema is reabsorbed, causing systemic and pulmonary hypervolemia, with consequent aggravation of pulmonary congestion, ultimately leading to PND. The client may bolt right out of bed and gasp for breath. In contrast with orthopnea, which may be relieved by immediately sitting up in bed, PND may require 30 minutes or longer in this position for relief (Dumitru & Sharma, 2023).
Assess oxygen saturation with pulse oximetry both at rest and during and after ambulation.
An alteration in oxygen saturation is one of the earliest signs of reduced cardiac output. Hypoxemia is common, especially with activity. Clients with mild to moderate heart failure may have normal oxygen saturations at rest, but they may exhibit marked reductions in oxygen saturations during physical exertion or recumbency.
Determine the pattern of sleep and rest.
Sleep-related events are associated with worsening cardiac disease, especially heart failure. A sudden fluid shift increases the preload, placing an increased demand on the heart of a client with heart failure and resulting in pulmonary congestion. This can affect the client’s sleeping patterns as paroxysmal nocturnal dyspnea may occur, as well as sleep-disorder breathing or obstructive sleep apnea. The cardinal signs include loud disruptive snoring and apnea that lasts for 10 seconds or more.
Note chest pain. Identify location, radiation, severity, quality, duration, associated manifestations such as nausea, and precipitating and relieving factors.
Chest pain or chest discomfort generally suggests myocardial ischemia or inadequate blood supply to the heart, which can compromise cardiac output (Yancy et al., 2017). Myocardial ischemia develops when coronary blood flow becomes inadequate to meet myocardial oxygen demand. Angina pectoris is the most common clinical manifestation of myocardial ischemia (Alaeddini & Yang, 2018).
Place on a cardiac monitor; monitor for dysrhythmias, especially atrial fibrillation.
Atrial fibrillation is common in heart failure and can cause a thromboembolic event. Hardwire cardiac monitoring is used to continuously observe the heart for dysrhythmias and conduction disorders. A real-time ECG is displayed on a bedside monitor and at a central monitoring station.
Monitor bowel function. Provide stool softeners as ordered. Instruct the client to avoid straining when defecating.
Decreased activity can cause constipation. When defecating, which results in the Valsalva maneuver, straining can lead to dysrhythmia, decreased cardiac function, and sometimes death. There are reports of syncope, chest pain, and arrhythmias due to the performance of the Valsalva maneuver. Therefore, caution is necessary for clients with pre-existing coronary artery disease, valvular disease, or congenital heart disease.
Observe the client for understanding and adherence to the medical regimen, including medications, activity level, and diet.
This promotes the cooperation of the client in their own medical situation. Because nonadherence to diet and medication can have rapid and profound adverse effects on the client’s status, close observation, and follow-up are important aspects of care.
Monitor blood pressure, pulse, and condition before administering cardiac medications such as angiotensin-converting enzyme (ACE) inhibitors, digoxin, and beta-blockers such as carvedilol. Notify the healthcare provider if the heart rate or blood pressure is low before holding medications.
The nurse must assess how well the client tolerates current medications before administering cardiac medications; do not hold medications without provider input. The healthcare provider may decide to have medications administered even though the blood pressure or pulse rate has lowered. Antiarrhythmic agents can have cardiodepressant effects and may promote arrhythmias. Calcium channel blockers can worsen heart failure and may increase the risk of cardiovascular events.
Inspect fluid balance and weight gain. Weigh the client regularly before breakfast.
Compromised regulatory mechanisms may result in fluid and sodium retention and increase fluid volume. Body weight is a more sensitive indicator of fluid or sodium retention than intake and output. Primary prevention for the general public should focus on the maintenance of a body mass index (BMI) of less than 25 kg/m² (King & Lowery, 2022).
Check for pedal and sacral edema.
Edema is a determining characteristic of heart failure. Edema on the feet, ankles, or legs is called peripheral edema. Edema can also be observed in the sacral area of clients on bed rest. Pitting edema, or an indentation in the skin created by finger pressure, can be assessed by using the thumb to place firm pressure over the dorsum of each foot, behind the malleolus, over the shins, or sacral area for five seconds. The degree of pitting edema relies on the examiner’s judgment of the depth of edema and the time the indentation remains after the release of pressure.
Monitor urine output. If the client is acutely ill, measure hourly urine output and note a decrease in output.
Urine output is an important indicator of cardiac function. Reduced cardiac output results in reduced perfusion of the kidneys, with a resulting decrease in urine output. When the urine output is decreased, the client must be assessed for a distended bladder or difficulty voiding.
Assess beta-type natriuretic peptide (BNP).
BNP is a neurohormone that helps regulate BP and fluid volume, it is primarily secreted from the ventricles in response to increased preload with resulting elevated ventricular pressure. The level of BNP in the blood increases as the ventricular walls expand from increased pressure, making it a helpful diagnostic, monitoring, and prognostic tool in the setting of heart failure.
If hemodynamic monitoring is in place, assess central venous pressure (CVP), pulmonary artery diastolic pressure (PADP), pulmonary capillary wedge pressure (PCWP), as well as cardiac output, and cardiac index.
CVP provides information on filling pressures of the right side of the heart; PADP and PCWP reflect left-sided fluid volumes. The cardiac output provides an objective number to guide therapy. To perform hemodynamic monitoring, a CVP, pulmonary artery, or arterial catheter is introduced into the appropriate blood vessel or heart chamber. The longer any of these catheters are in place, the greater the risk of infection. Therefore, nurses handling this equipment must demonstrate competence prior to caring independently for a client requiring hemodynamic monitoring.
Closely monitor for symptoms of heart failure and decreased cardiac output.
Signs and symptoms of heart failure include tachycardia and manifestations of venous congestion, such as edema, and low cardiac output (fatigue). Breathlessness is a cardinal symptom of left ventricular failure that may manifest with progressively increasing severity.
Assess for reports of fatigue and reduced activity tolerance.
Fatigue and exertional dyspnea are common problems with low cardiac output states. Close monitoring of the client’s response serves as a guide for the optimal progression of activity. As heart failure first develops, exertional dyspnea may simply appear to be an exacerbation of the breathlessness that occurs in a healthy client during activity, but as LV failure advances, the intensity of exercise resulting in breathlessness progressively declines.
Ascertain contributing factors so an appropriate care plan can be initiated.
Recognizing these factors can help guide the treatment regimen. Impairment of cardiac function can arise through different pathophysiologic mechanisms. This includes hypertension, coronary disease, congenital problems, myocardial ischemia, infarction, congestive heart failure, shock, arrhythmias, genetic diseases, structural abnormalities, pericardial effusions, emboli, tamponade, and many more.
Monitor electrocardiogram (ECG) for rate, rhythm, and ectopy.
Cardiac dysrhythmias may occur from low perfusion, acidosis, or hypoxia. Tachycardia, bradycardia, and ectopic beats can further compromise cardiac output. Older adult clients are susceptible to the loss of atrial kick in atrial fibrillation. The 12-lead ECG is used to diagnose dysrhythmias, conduction abnormalities, and chamber enlargement, as well as myocardial ischemia, injury, or infarction. It can also suggest the cardiac effects of electrolyte disturbances and the effects of antiarrhythmic medications.
Review results of EKG and chest X-ray.
These tests can help indicate the underlying cause of decreased cardiac output. EKG can reveal previous MI or left ventricular hypertrophy, indicating aortic stenosis or chronic systemic hypertension. A chest X-ray may provide information on pulmonary edema, pleural effusions, or enlarged cardiac silhouette found in dilated cardiomyopathy or large pericardial effusion.
Examine laboratory data, especially arterial blood gases (ABG) and electrolytes, including potassium.
The client may be receiving cardiac glycosides, and the potential for toxicity is greater with hypokalemia; hypokalemia is common in heart clients because of diuretic use. Indications for ABG analysis include severe respiratory distress, documented hypoxemia by pulse oximetry not responsive to supplemental oxygen, and evidence of acidosis by serum chemistry findings or elevated lactate levels.
Monitor laboratory tests such as complete blood count, sodium level, BUN, and serum creatinine.
Routine blood work can provide insight into the etiology of heart failure and the extent of decompensation. A low serum sodium level often is observed with advanced heart failure and can be a poor prognostic sign. Serum creatinine and BUN levels will elevate in clients with severe heart failure because of decreased perfusion to the kidneys from reduced cardiac output. Creatinine may also elevate because of ACE inhibitors. Overaggressive diuresis may aggravate renal insufficiency due to volume depletion.
Assess the availability of social support.
Clients with complex cardiovascular disorders may require management through sophisticated technology, such as implantable cardioverter defibrillators and left ventricular assist devices. Having an adequate social support system, such as family members or friends, may help reduce the burden of self-care. Additionally, social support has been linked to positive CVD outcomes, according to the American Heart Association (AHA).
Inadequate cardiac output leads to reduced oxygen delivery to tissues, resulting in impaired tissue perfusion and oxygenation. This can cause tissue hypoxia and organ dysfunction. The nurse must closely monitor the client’s vital signs and assess for signs of poor tissue perfusion. Addressing impaired oxygenation and tissue perfusion is a priority to ensure organ function.
Instruct the client in performing a 6-minute walk test.
The nurse may conduct a 6-minute walk test to identify the client’s ventricular rate associated with exercise. The nurse asks the client to walk for six minutes at as much distance as tolerated as the nurse monitors for symptoms. At the end of the procedure, the nurse documents the distance that the client has covered, the pre-and post-exercise heart rate, and the client’s response to the test.
Place the client in a comfortable position that facilitates breathing.
The client may be positioned or taught how to assume a position that facilitates breathing. The number of pillows may be increased, the head of the bed may be elevated, or the client may sit in a recliner. In these positions, the venous return to the heart or preload is reduced, pulmonary congestion is reduced, and the pressure on the diaphragm is minimized. The lower arms can be supported with pillows to eliminate teh fatigue caused by the pull of the client’s weight on the shoulder muscles.
Maintain adequate ventilation and perfusion through proper positioning of the client.
Position client in semi-Fowler to high-Fowler. An upright position is recommended to reduce preload and ventricular filling when fluid overload is the cause. Place the client in a supine position. For hypovolemia, supine positioning increases venous return and promotes diuresis. Proper positioning helps prevent the compression of major blood vessels by avoiding undue pressure on the chest or abdomen. This ensures blood flow to and from the heart is not compromised, allowing the organ to function more efficiently.
During acute events, ensure the client remains on bed rest or maintains an activity level that does not compromise cardiac output.
In severe heart failure, restriction of activity often facilitates temporary recompensation. For example, if the client is able to perform minimal activities of daily living, suggesting that the client sit while chopping vegetables, drying their hair, or shaving may help them learn to balance rest with activity. These clients must avoid strenuous activities, isometric exercises, and competitive sports.
Encourage the client to engage in exercise training as indicated.
A supervised exercise program with endurance and resistance training with a focus on the core and the lower body may provide the greatest benefit for a client with decreased cardiac output. Studies show that physical fitness may increase stroke volume over time. The client may start with a horizontal mode of training, such as swimming or recumbent cycles, performing it consistently thrice a week.
Apply music therapy to decrease anxiety and improve cardiac function.
Research suggests that music could inhibit and balance brain waves, capable to activate the limbic system related to emotion. When the limbic system is activated, the client would feel relaxed. Music also affects the release of stress-release hormones and stimulates the production of nitric oxide molecules that works on blood vessel tone, decreasing blood pressure (Astuti et al., 2019).
Instruct maneuvers that can alleviate orthostatic hypotension.
In the case of acute symptoms of orthostatic hypotension, the nurse may instruct the client on the physical countermeasures that can quickly improve venous return. These include leg crossing, muscle tensing, muscle pumping by sway-and-shift or tiptoe walking, bending forward, sitting/squatting/lying supine, squeezing a rubber ball with contraction of the leg and abdominal muscles, breathing techniques, buttock clenching, sitting with the head between the knees, and skin-surface cooling.
Ensure that the balloon tip is deflated after measurement of pulmonary artery wedge pressure (PAWP).
After measuring the PAWP, the nurse must ensure that the balloon tip is deflated and the catheter has returned to its normal position. PAWP is achieved by inflating the balloon tip, which allows it to be wedged in a smaller portion of the pulmonary artery. This is an occlusive maneuver and may impede blood flow through that part of the pulmonary artery. The nurse may verify this through the pulmonary artery pressure waveform displayed on the bedside monitor.
Apply waist-high compression stockings or abdominal binders for the client as indicated.
Over-the-knee, or ideally, waist-high compression of the lower extremities (30 to 40 mm Hg) helps decrease venous pooling, thus attenuating the reduction in stroke volume and perfusion when the client is in an upright position. Tight-fitted abdominal binders are also effective because the lower abdomen and pelvis contain 20 to 30% of the total blood volume.
Administer oxygen therapy as prescribed.
The failing heart may not be able to respond to increased oxygen demands. Oxygen saturation needs to be greater than 90%. Administration of oxygen, if oxygen saturation is less than 90%, and noninvasive positive pressure ventilation (NIPPV) provides clients with respiratory support to avoid intubation.
Administer medications as prescribed, noting side effects and toxicity.
Depending on etiological factors, common medications include digitalis therapy, diuretics, vasodilator therapy, antidysrhythmics, angiotensin-converting enzyme inhibitors, and inotropic agents. Control of the occurrence or the effect of dysrhythmia can be achieved with antiarrhythmic medications. Commonly used medications for decreased cardiac output in heart failure can be found here.
Angina pectoris is the result of myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand. Increases in heart rate and myocardial contractile state result in increased myocardial oxygen demand. Increases in both afterload and preload result in a proportional elevation of myocardial wall tension, and therefore, increased myocardial oxygen demand.
If chest pain is present, have the client lie down, monitor cardiac rhythm, give oxygen, run a strip, medicate for pain, and notify the healthcare provider.
These actions can increase oxygen delivery to the coronary arteries and improve the client’s prognosis. Symptoms can also be manifestations of myocardial ischemia and should be reported immediately. The main goals of treatment for chest pain are to relieve the symptoms, slow the progression, and reduce the possibility of the development of myocardial ischemia or premature death.
Position the client in a semi-Fowler position during acute angina episodes.
The client experiencing angina should be instructed to stop all activities and sit or rest in bed in a semi-Fowler position to reduce the oxygen requirements of the ischemic myocardium.
Encourage the client to stop smoking.
Smoking cessation results in a significant decrease in acute adverse effects on the heart and allows slow, reversible atherosclerosis. The nurse should strongly encourage the client to stop smoking and take an active role in helping them achieve this goal through constant follow-up.
Promote a well-balanced diet low in saturated fat and sodium.
Recent guidelines from the American College of Cardiology and American Heart Association, the European Society of Cardiology, and the World Health Organization all recommended following a varied diet including vegetables, fruits and seaweeds, and plenty of milk and milk processed foods for prevention and management of cardiovascular diseases. Saturated fatty acids and trans fatty acids should be replaced with unsaturated fatty acids such as fish and nuts. Salt intake should be restricted to a decent amount, along with an adequate intake of micronutrients and avoidance of carbonated drinks (Cho et al., 2021).
Plan the client’s schedule for adequate rest and activities.
After identifying the level of activity that causes the client’s pain, the nurse plans the client’s activities accordingly. If the client has pain frequently or with minimal activity, the nurse should alternate activities with rest periods. Balancing activity and rest is an important aspect of the educational plan for the client and the family.
Instruct the client to avoid extremes in temperature.
The client should be aware that temperature extremes, especially cold, may induce anginal pain. Therefore, when exercising, the client should avoid temperature extremes such as under direct sunlight or in a small, air-conditioned room.
Administer medications as prescribed.
The goal of pharmacological therapy in angina is to reduce morbidity and prevent the development of complications.
Administer oxygen therapy as indicated.
The nurse administers oxygen therapy if the client’s respiratory rate is increased or if the oxygen saturation level is decreased. Oxygen is usually given at 2 liters per minute by nasal cannula, even without evidence of desaturation.
Prepare the client for revascularization therapy as appropriate.
Revascularization therapy can be considered in clients with LV dysfunction and severe symptoms despite maximum medical therapy. The two main coronary revascularization procedures are percutaneous transluminal coronary angioplasty and coronary artery bypass grafting (CABG).
Assist in the management of implantable cardioverter defibrillators (ICD).
The ICD is an electronic device that detects and terminates life-threatening episodes of tachycardia or fibrillation, especially those that are ventricular in origin. An ICD has a generator about the size of a book of matches that is implanted in a subcutaneous pocket, usually in the upper chest wall. It also has a right ventricular lead that is implanted transvenously and can sense intrinsic electrical activity and deliver an electrical impulse.
Clients with decreased cardiac output have dietary and fluid restrictions, particularly sodium and fluid intake. The nurse should collaborate with a dietitian to develop and heart-healthy diet plan, educate the client on dietary and fluid modifications and monitor the nutritional status and fluid intake and output.
Monitor the client for signs and symptoms of fluid overload or dehydration.
Early recognition of fluid imbalance allows prompt intervention, minimizing the risk of complications and improving cardiac output. All too often, a client’s new symptoms or those of progressing cardiac dysfunction go unrecognized. This results in prolonged delays in seeking life-saving treatment.
Identify the client’s fluid responsiveness prior to administering fluid management.
Measuring changes in cardiac output in response to a passive leg raise maneuver may define volume responsiveness and can be sued to attempt fluid loading. The nurse should then assess the client’s response to the intervention (Vieillard-Baron et al., 2018).
Elevate the head of the bed and assist the client in activities of daily living.
Elevating the head of the bed reduces preload, making it easier for the heart to pump blood. Assisting the client with ADLs conserves the client’s energy and prevents exertion-related stress on the heart.
Closely monitor fluid intake, including IV lines. Maintain fluid restriction if ordered.
In clients with decreased cardiac output, poorly functioning ventricles may not tolerate increased fluid volumes. For example, in a client with congestive heart failure, fluid retention occurs as a result of decreased cardiac output, which in turn was caused by the left ventricular failure. This can cause serious consequences to the client, thus fluid restriction is warranted (Roumelioti et al., 2018).
For clients with increased preload, limit fluids and sodium as ordered.
Fluid restriction decreases the extracellular fluid volume and reduces demands on the heart. A dietary sodium restriction of 2 to 3 grams per day is recommended. Fluid restriction to two liters per day is recommended for clients whose fluid status cannot be controlled despite imposed sodium restriction and administration of high-dose diuretics.
Offer small, frequent meals with nutrient-dense foods.
Smaller, frequent meals are easier for the heart to handle than large, heavy meals. Nutrient-dense foods can help meet the client’s nutritional requirements without overwhelming the cardiovascular system.
Promote avoidance of additives and processed foods.
Added food substances or additives, such as sodium alginate, which improves food texture, sodium benzoate, which acts as a preservative, and disodium phosphate, which improves cooking quality in certain foods, increase the sodium intake when included in the daily diet.
Consider the client’s food preferences.
The client’s food preferences must be taken into account- diet counseling and educational handouts can be eager to individual and ethnic preferences- and the family should be involved in the dietary education as well. A variety of flavorings, such as lemon juice, vinegar, and herbs, may be used to improve the taste of the food and facilitate acceptance of the diet.
Instruct the client to check the labels of commercial foods carefully.
Clients on low-sodium diets should be advised to carefully check the labels for words such as “salt” or “sodium”, especially on canned foods. Potato chips have a lower sodium content than a cup of canned mushroom soup, although potato chips are still not recommended in a low-sodium diet.
Caution the client in ingesting large amounts of water and taking over-the-counter medications.
Sodium is contained in municipal water. Water softeners also increase the sodium content of drinking water. Patients on sodium-restricted diets should also be cautioned against using nonprescription medications such as antacids, cough syrups, and laxatives.
Administer colloids or crystalloids as prescribed.
Hypertonic saline and colloids, including albumin, may be used to boost intravascular volume, as well as mannitol. Isotonic saline administration is problematic since it limits the achievement of a negative fluid balance (Kanbay et al., 2020).
Administer vasopressors as indicated.
A primary treatment to sustain cardiovascular function is the administration of vasopressors, such as norepinephrine, vasopressin, or terlipressin, to keep the systemic arterial pressure greater than the pulmonary arterial pressure in acute ventricular failure. Norepinephrine infusion restored mean arterial pressure to baseline, decreasing biventricular filling pressure and increasing cardiac index. In pulmonary embolism, dobutamine has been reported to improve hemodynamics and reduce pulmonary vascular resistance.
Cardiopulmonary resuscitation (CPR) provides blood flow to vital organs until effective circulation can be reestablished. This should be taught to healthcare professionals and caregivers alike to improve outcomes following a life-threatening cardiac event. Lay rescuer CPR improves survival from cardiac arrest by two to three-fold.
Assess the client for responsiveness and breathing.
It has been shown previously that all rescuers may have difficulty detecting a pulse, leading to delays in CPR, or in some cases CPR not being performed at all for a client in cardiac arrest. Recognition of cardiac arrest by lay rescuers, therefore, is determined on the basis of the level of consciousness and the respiratory effort of the client. Recognition of cardiac arrest by healthcare professionals includes a pulse check.
Activate the Emergency Response System (ERS).
Within a medical facility, the nurse should make a call to alert the emergency response team, often called the “Code 4” or “Code Blue” team. Outside of the medical facility, 911 is called to activate the Emergency Medical Service (EMS). In the rare situation when a lone rescuer must leave the client to dial EMS, the priority should be on prompt EMS activation followed by an immediate return to the client for CPR.
Initiate CPR after recognition of cardiac arrest.
The prompt initiation of CPR is perhaps the most important intervention to improve survival and neurological outcomes. Lay rescuers may provide chest compression-only CPR to simplify the process and encourage CPR initiation, whereas healthcare professionals may provide chest compressions and ventilation (30 compressions and 2 breaths).
Administer rescue breaths as appropriate.
Rescue breaths are only recommended if the healthcare provider is the one doing it. This is started after chest compressions. Using a head-tilt/chin-lift maneuver, the airway is opened for the removal of any obstruction present. Rescue ventilations may be provided using a bag-valve mask or mouth-mask device, or an oropharyngeal airway may be inserted if available.
Perform defibrillation as soon as an automated external defibrillate (AED) is available.
Monitor electrodes are applied to the client’s chest and the heart rhythm is analyzed. When using an AED, the device is turned on, the pads are applied to the chest, and the rhythm is analyzed to determine if a shock is indicated. The survival time decreases for every minute that defibrillation is delayed if it is indicated.
Assist in the insertion of an artificial airway as appropriate.
Placement of an advanced airway such as an ET tube may be performed to ensure a patent airway and adequate ventilation. Tracheal intubation placement must be confirmed by auscultation of breath sounds, observation of chest expansion, and a carbon dioxide detector. A chest X-ray may be obtained after ET tube placement to confirm the proper positioning of the tube.
Provide strict follow-up monitoring and care.
After transfer to the intensive care unit for close monitoring, the client should have continuous ECG monitoring and frequent blood pressure assessments until hemodynamic stability is established. The care of the client following resuscitation is another determinant of survival. Causative factors for the arrest must be identified and treated promptly.
The client and their families may have a limited understanding of the condition and its management. The nurse must provide comprehensive education on the disease process, treatment plan, lifestyle modifications, and potential complications to empower the client toward self-management.
Identify an emergency plan, including the use of cardiopulmonary response (CPR).
Persistent decreased cardiac output can be life-threatening. CPr is considered the hallmark of cardiac arrest management for a long time, with updates and developments to improve its performance. According to the American Heart Association, during manual CPR, the reducer should perform chest compressions with a depth of at least 2 inches, or 5 cm. Avoidance of excessive chest compression depths of greater than 2.4 inches or 6 cm must be avoided. The rate should be at 100 to 120/minute (Merchant et al., 2020).
Assess the client’s and family members’ ability to recognize cardiac symptoms.
The client’s and family members’ abilities to recognize cardiac symptoms and the appropriate corresponding interventions are crucial for self-management and home care. Major barriers to seeking prompt medical care include a lack of knowledge about the symptoms of heart disease, attributing symptoms to a benign source, denying symptom significance, and feeling embarrassed about having symptoms.
Assess the client’s and caregiver’s understanding of the disease process and therapeutic regimen and explain these topics in a simple manner.
When educating clients about cardiovascular dysfunction, the nurse should first assess the client’s and caregiver’s understanding, clarify misinformation, and share needed information in terms that are understandable and in a manner that is not frightening or threatening.
Advise the client to use a commode or urinal for toileting and avoid using a bedpan.
Getting out of bed to use a commode or urinal does not stress the heart more than staying in bed to the toilet. In addition, getting the client out of bed minimizes complications of immobility and is often preferred by the client. Accessibility of a toilet empowers the client to maintain a level of independence and privacy in their daily routines, enhancing their sense of dignity.
Encourage the client to adopt a healthy lifestyle. Explain the importance of smoking cessation and avoidance of alcohol intake.
Educating the client on the effects of smoking can help them understand the health risks involved in smoking. Smoking is associated with an increased risk of heart failure, but the risk decreases with increasing duration since smoking cessation (Aune et al., 2019). Any form of heavy drinking of alcohol should be discouraged (Rehm & Roerecke, 2017). These measures can help improve cardiac output and overall health.
Educate the client and significant other about the disease process, complications of the disease process, information on medications, the need for weighing daily, and when appropriate to call a primary care provider.
Early recognition of symptoms facilitates early problem-solving and prompt treatment. Offer ongoing support and encourage the client to ask questions and express any concerns they may have. Clients who do not understand the connection between risk factors and cardiovascular diseases may be unwilling to make recommended lifestyle changes or manage their illness effectively.
Aid the family to adapt daily living patterns to establish life changes that will maintain improved cardiac functioning in the client.
Transitioning to the home setting can cause risk factors such as inappropriate diet to reemerge. A referral for home, community-based or transitional care usually is not necessary for the client unless the client is hemodynamically unstable and has significant symptoms of decreased cardiac output.
Educate clients on the need for and how to incorporate lifestyle changes.
Psychoeducational programs including information on stress management and health education have been shown to reduce long-term mortality and recurrence of myocardial infarction in heart clients. The client and the family also need to be educated about measures to take to decrease the risk of recurrence of heart abnormalities, such as collaborating with the nurse for a plan of action in case of an emergency or encouraging a family member to take up CPR training.
Provide emotional support.
The nurse should remain calm while offering to stay with the client to provide an assurance of safety and security. Listen to the concerns of the clients and answer their questions. Provide accurate, clear, and concise information about their condition and treatment options, as well as supportive or empathetic statements or assist the client in recognizing their emotions (anger, frustration, anxiety). Connect clients with support groups or counseling services.
Instruct the client on how to avoid infection at the insertion site.
Infection at the insertion site is possible, therefore, the site should be regularly examined for redness, increased swelling, and heat. The client may take their temperature daily at the same time each day and report any increase. Soaking in bathtubs, as well as the use of lotions, and powders in the area of the device must be avoided initially to avoid irritating the site. Tight, restrictive clothing must be avoided because it may cause friction over the insertion site.
Educate on checking the pulse regularly.
The nurse instructs the client to check their pulse daily and report immediately if there is any sudden slowing or increase of the pulse rate. This may indicate pacemaker malfunction.
Explain the importance of electromagnetic interference.
Instruct to avoid large magnetic fields, such as MRIs, large motors, arc welding, and electrical substations. These may deactivate the device, negating its effect on dysrhythmia. Show an identification card at security gates, government buildings, and other secured areas and request for only a hand search. Obtain and carry a letter from the healthcare provider about the presence of an ICD in the body for these situations.
Instruct the client to adhere to activity limitations,
Inform the client tat the movement of the arms should be restricted until the incision heals. The arm may not be raised above the head for two weeks and heavy lifting must be avoided for a few weeks. However, physical activity prescribed by the healthcare provider should not be stopped, except for contact sports.
Provide precautions and safety measures.
Encourage the client to keep a log or record discharges of the ICD and the events that precipitate the sensation of shock. Thai provides essential data for the provider to use in readjusting the medical regimen. Provide a medical alert bracelet for the client to wear that includes the healthcare provider’s information. Additionally, the client should also carry medical identification with the type and model number of the device, manufacturer’s name, and hospital where the device was inserted.
Explain to caregivers and family members the effects of the ICD on them.
Explain to family members and caregivers that when they are in contact with the client and a shock is delivered, and they will feel the shock too. However, avoid frightening them with unexpected shocks because these will not harm them. This is especially important for sexual partners to know.
Additional interventions: See additional interventions for decreased cardiac output in our heart failure nursing care plan.
Conditions and diseases that are related to a decrease in cardiac output:
Recommended nursing diagnosis and nursing care plan books and resources.
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
Recommended journals, books, and other interesting materials to help you learn more about decreased cardiac output nursing diagnosis:
Gil Wayne ignites the minds of future nurses through his work as a part-time nurse instructor, writer, and contributor for Nurseslabs, striving to inspire the next generation to reach their full potential and elevate the nursing profession.
Thank you very much for this piece…it was useful and educating. I’m happy to see Nurses glow..🙌 Reply
