Decreased Cardiac Output Nursing Diagnosis: A Comprehensive Guide

Cardiac output (CO) is a vital measurement in healthcare, representing the volume of blood the heart pumps per minute, typically expressed in liters per minute (L/min). It’s a product of two key factors: stroke volume (SV), the amount of blood ejected from the left ventricle with each heartbeat, and heart rate (HR). Beyond SV and HR, cardiac output is also influenced by preload, afterload, and contractility – factors that nurses must understand to provide optimal patient care.

Decreased cardiac output (DCO) is a critical nursing diagnosis that indicates the heart isn’t pumping enough blood to meet the body’s metabolic needs. This inadequacy can lead to a cascade of physiological and psychological symptoms, demanding prompt recognition and intervention by nurses.

Unpacking the Causes of Decreased Cardiac Output

Numerous conditions can lead to a reduction in cardiac output. Understanding these underlying causes is crucial for effective nursing care and targeted interventions. Here are some significant contributors to decreased cardiac output:

• Hypertension: Chronically elevated blood pressure increases the heart’s workload, potentially leading to heart muscle thickening (hypertrophy) and eventual heart failure, thus reducing cardiac output.
• Coronary Artery Disease (CAD): Narrowing or blockage of coronary arteries reduces blood flow to the heart muscle (myocardium). This ischemia can impair heart function and decrease stroke volume and consequently, cardiac output.
• Genetic Cardiac Diseases: Inherited conditions affecting the heart’s structure or function, such as hypertrophic cardiomyopathy or congenital heart defects, can directly impair the heart’s ability to pump blood effectively.
• Myocardial Ischemia/Infarction (MI): Reduced blood supply (ischemia) or complete blockage (infarction/heart attack) damages heart muscle, weakening contractility and significantly decreasing cardiac output.
• Congestive Heart Failure (CHF): This chronic condition progressively weakens the heart’s pumping ability. CHF is a major cause of decreased cardiac output, as the heart struggles to meet the body’s circulatory demands.
• Shock: Various types of shock (hypovolemic, cardiogenic, septic, anaphylactic, neurogenic) can lead to decreased cardiac output. In cardiogenic shock, the heart’s pumping ability is directly compromised. Other forms of shock indirectly reduce CO through factors like decreased blood volume or systemic vasodilation.
• Arrhythmias: Irregular heart rhythms, whether too fast (tachycardia) or too slow (bradycardia), can disrupt the heart’s efficient pumping action, leading to reduced cardiac output. Atrial fibrillation and ventricular tachycardia are examples of arrhythmias that can significantly impact CO.
• Cardiac Structural Abnormalities: Conditions like valvular heart disease (stenosis or regurgitation) and cardiomyopathies can physically impede blood flow and reduce the heart’s efficiency in pumping blood.
• Pericardial Effusions: Fluid accumulation in the pericardial sac (the sac surrounding the heart) can compress the heart, restricting its ability to fill and pump effectively, thus decreasing cardiac output.
• Cardiac Tamponade: A severe form of pericardial effusion where rapid fluid accumulation critically compresses the heart, severely restricting ventricular filling and leading to a drastic reduction in cardiac output and is a life-threatening emergency.

This list is not exhaustive, and it’s vital to remember that the development of decreased cardiac output can be gradual, with subtle initial symptoms. Nurses play a crucial role in recognizing early indicators and understanding how various cardiac conditions can ultimately compromise a patient’s cardiac output.

Recognizing Signs and Symptoms of Decreased Cardiac Output

The manifestations of decreased cardiac output are diverse, impacting multiple body systems. Nurses must be vigilant in assessing for both physiological and psychological signs and symptoms.

Physiological Signs and Symptoms:

• Hypotension: Reduced cardiac output often leads to lower blood pressure as the heart struggles to maintain adequate circulatory pressure.
• Hypercapnia: Inefficient blood circulation can lead to a buildup of carbon dioxide in the blood (hypercapnia) due to impaired gas exchange.
• Cardiac Arrhythmias: Decreased cardiac output can be both a cause and a consequence of arrhythmias. The underlying conditions causing DCO can also predispose to irregular heart rhythms.
• Chest Pain (Angina): Reduced blood flow to the heart muscle can cause chest pain, particularly during exertion or stress, indicating myocardial ischemia.
• Poor Tissue Perfusion: Inadequate cardiac output results in insufficient oxygen delivery to tissues, manifesting as:
  • Diminished Peripheral Pulses: Pulses in the extremities may be weak, thready, or difficult to palpate.
  • Clammy, Cool Skin: Blood is shunted away from the periphery to vital organs, causing the skin to become cool, pale, and moist.
• Dizziness, Lightheadedness, Syncope: Reduced blood flow to the brain can cause dizziness, lightheadedness, and even fainting (syncope).
• Fatigue and Weakness: Insufficient oxygen delivery to muscles leads to generalized fatigue and weakness, even with minimal activity.
• Edema: Fluid retention due to decreased renal perfusion and neurohormonal responses can cause edema, particularly in the lower extremities (peripheral edema) or lungs (pulmonary edema).
• Decreased Urine Output (Oliguria): Reduced blood flow to the kidneys impairs their filtering function, leading to decreased urine production.
• Altered Mental Status: Inadequate oxygen supply to the brain can manifest as confusion, disorientation, restlessness, and even loss of consciousness.

Psychological Signs and Symptoms:

• Restlessness: A sense of unease and agitation can be an early sign of decreased oxygen delivery to the brain.
• Anxiety: The body’s stress response to reduced cardiac output can trigger anxiety and apprehension.
• Altered Mental Status/Confusion: As mentioned earlier, changes in cognitive function, ranging from mild confusion to significant disorientation, can occur.

It’s essential to recognize that these signs and symptoms can vary in presentation and severity depending on the underlying cause, the rapidity of onset, and the individual patient’s compensatory mechanisms. A comprehensive nursing assessment is crucial for identifying decreased cardiac output and initiating timely interventions.

Expected Outcomes for Patients with Decreased Cardiac Output

Nursing care planning for decreased cardiac output focuses on achieving specific, measurable outcomes that reflect improved cardiac function and patient well-being. Common expected outcomes include:

• Adequate Cardiac Output: The patient will demonstrate improved cardiac output, evidenced by:
  • Blood pressure, heart rate, and heart rhythm within the patient’s normal limits or acceptable parameters.
  • Strong peripheral pulses.
  • Warm and dry skin.
  • Alert and oriented mental status.
  • Adequate urine output.
• Return to Baseline Activity Level: The patient will gradually regain their pre-illness activity tolerance without experiencing excessive fatigue, shortness of breath, or chest pain.
• Adequate Breathing and Oxygenation: The patient will exhibit effective breathing, indicated by:
  • Appropriate oxygen saturation levels (as prescribed by physician).
  • Absence of adventitious breath sounds (e.g., crackles, wheezes).
  • Respiratory rate and pattern within normal limits.
• Verbalization of Self-Care Strategies: The patient will be able to articulate understanding of their condition and demonstrate knowledge of self-care activities to promote cardiac health and prevent further deterioration. This includes medication management, dietary modifications, activity guidelines, and recognition of warning signs requiring medical attention.

These outcomes serve as a roadmap for nursing interventions and provide a framework for evaluating the effectiveness of care.

Comprehensive Nursing Assessment for Decreased Cardiac Output

A thorough nursing assessment is the cornerstone of managing decreased cardiac output. It involves systematic data collection across various domains:

1. Monitor Heart Rate and Blood Pressure:

• Rationale: Low cardiac output triggers the sympathetic nervous system to compensate. Initially, this may cause an increased heart rate (tachycardia) and potentially elevated blood pressure as the body attempts to maintain perfusion. However, as DCO worsens, the heart may fail to sustain compensation, leading to hypotension.
• Nursing Action: Regularly assess and document heart rate, rhythm, and blood pressure. Note trends and report significant changes.

2. Monitor Breath Sounds, Respiratory Rate and Pattern, and Oxygen Saturation:

• Rationale: Decreased cardiac output can lead to pulmonary congestion and impaired gas exchange, resulting in shortness of breath (dyspnea) and hypoxemia. Adventitious breath sounds like crackles (rales) may indicate fluid accumulation in the lungs.
• Nursing Action: Assess respiratory rate, depth, and effort. Auscultate breath sounds for abnormalities. Continuously monitor oxygen saturation using pulse oximetry. Report signs of respiratory distress or declining oxygen saturation.

3. Monitor Heart Rhythm (ECG Monitoring):

• Rationale: Decreased cardiac output can both cause and be caused by cardiac arrhythmias. Arrhythmias like atrial fibrillation are common in patients with DCO. Ventricular tachycardia is a life-threatening arrhythmia requiring immediate intervention.
• Nursing Action: Initiate continuous ECG monitoring to detect arrhythmias. Document and report any rhythm disturbances. Be prepared to respond to life-threatening arrhythmias according to established protocols.

4. Monitor Heart Sounds:

• Rationale: Normal heart sounds (S1 and S2) may be diminished with poor heart function. Abnormal heart sounds like S3 and S4 can indicate heart failure and reduced cardiac output.
• Nursing Action: Auscultate heart sounds for rate, rhythm, and the presence of S1, S2, S3, and S4 sounds, murmurs, or rubs. Document and report any abnormal findings.

5. Assess Peripheral Pulses:

• Rationale: Decreased cardiac output leads to reduced tissue perfusion, causing peripheral pulses to become weak, thready, or difficult to palpate.
• Nursing Action: Palpate peripheral pulses (radial, pedal, posterior tibial, femoral) bilaterally, assessing for rate, rhythm, and amplitude (strength). Document findings and report diminished or absent pulses.

6. Assess Skin Color and Temperature:

• Rationale: Poor tissue perfusion due to decreased cardiac output results in reduced oxygen delivery to the skin, causing it to become cool, clammy, and pale or cyanotic (bluish discoloration).
• Nursing Action: Observe skin color (pallor, cyanosis) and temperature (cool, clammy) in extremities and trunk. Document findings and report changes indicative of poor perfusion.

7. Assess Patient’s Mental Status:

• Rationale: Reduced cerebral perfusion due to decreased cardiac output can lead to altered mental status, ranging from mild confusion to disorientation and decreased level of consciousness.
• Nursing Action: Assess level of consciousness, orientation to time, place, and person. Evaluate cognitive function and note any changes in behavior, restlessness, or confusion. Document and report alterations in mental status.

8. Assess Lab Values and Imaging Studies:

• Rationale: Laboratory tests (e.g., electrolytes, BUN, creatinine, cardiac enzymes, BNP) and imaging studies (e.g., echocardiogram, chest X-ray) can help identify underlying causes of decreased cardiac output and assess the severity of heart dysfunction.
• Nursing Action: Review and monitor relevant lab results and imaging reports. Understand the significance of abnormal findings in the context of decreased cardiac output. Report critical values to the physician and integrate findings into the overall assessment.

9. Monitor Weight Closely:

• Rationale: Decreased cardiac output can lead to fluid retention due to neurohormonal responses and reduced renal perfusion, causing weight gain.
• Nursing Action: Obtain daily weights, preferably at the same time each day, using the same scale. Monitor for rapid weight gain, which may indicate fluid accumulation. Document and report significant weight changes.

10. Monitor Intake and Output (I&O):

• Rationale: Monitoring fluid intake and output is essential to assess fluid balance and renal function, which are directly affected by cardiac output. Decreased urine output is a key indicator of reduced renal perfusion.
• Nursing Action: Accurately measure and record all fluid intake (oral, intravenous) and output (urine, drainage, emesis). Calculate fluid balance over 24 hours. Report significant discrepancies between intake and output, especially oliguria (decreased urine output).

11. Monitor Patient’s Activity Level and Tolerance:

• Rationale: Patients with decreased cardiac output experience fatigue and reduced exercise tolerance due to inadequate oxygen delivery to muscles.
• Nursing Action: Assess the patient’s ability to perform activities of daily living (ADLs). Monitor for fatigue, shortness of breath, chest pain, or dizziness during activity. Document activity tolerance and report any limitations.

By systematically performing these assessments, nurses can gather comprehensive data to identify decreased cardiac output, determine potential underlying causes, and monitor the patient’s response to interventions.

Essential Nursing Interventions for Decreased Cardiac Output

Nursing interventions for decreased cardiac output are aimed at improving cardiac function, optimizing oxygenation, reducing cardiac workload, and preventing complications. Key interventions include:

1. Administer Supplemental Oxygen as Needed:

• Rationale: Hypoxemia is common in decreased cardiac output. Supplemental oxygen increases arterial oxygen saturation, improving oxygen delivery to tissues and reducing myocardial ischemia.
• Nursing Action: Administer oxygen via nasal cannula, face mask, or non-rebreather mask as prescribed by the physician or according to established protocols. Monitor oxygen saturation and adjust oxygen delivery as needed to maintain target SpO2 levels.

2. Administer Prescribed Medications as Ordered:

• Rationale: Various medications are used to manage decreased cardiac output, depending on the underlying cause and patient’s condition. Common medications include:
  • ACE inhibitors and ARBs: Reduce afterload and promote vasodilation.
  • Beta-blockers: Reduce heart rate and myocardial oxygen demand.
  • Diuretics: Reduce fluid volume overload and preload.
  • Inotropes (e.g., digoxin, dobutamine): Increase myocardial contractility.
  • Vasodilators (e.g., nitroglycerin): Reduce preload and afterload, improve coronary blood flow.
• Nursing Action: Administer medications as prescribed, paying close attention to dosage, route, and timing. Monitor for therapeutic effects and potential side effects. Educate patients about their medications, including purpose, dosage, side effects, and importance of adherence.

3. Elevate the Head of the Bed:

• Rationale: Elevating the head of the bed (semi-Fowler’s or high-Fowler’s position) promotes lung expansion, improves ventilation, and reduces venous return (preload), easing the heart’s workload.
• Nursing Action: Position the patient with the head of the bed elevated to at least 30-45 degrees, unless contraindicated. Ensure proper body alignment and support with pillows for comfort.

4. Maintain Fluid and/or Sodium Restrictions:

• Rationale: Fluid and sodium retention worsen heart failure and decrease cardiac output. Restrictions help minimize fluid overload, reduce preload, and alleviate symptoms like edema and shortness of breath.
• Nursing Action: Implement fluid restrictions as prescribed by the physician. Monitor fluid intake and output closely. Educate patients and families about the importance of fluid and sodium restrictions and provide guidance on dietary modifications. Collaborate with dietary services as needed.

5. Bed Rest and Gradual Activity Progression:

• Rationale: During the acute phase of decreased cardiac output, bed rest reduces myocardial oxygen demand and conserves energy. As the patient stabilizes, gradual activity progression improves tolerance and prevents deconditioning.
• Nursing Action: Encourage bed rest during acute episodes. Once stable, collaborate with physical therapy to develop a progressive activity plan. Monitor patient’s response to activity and adjust the plan accordingly. Educate patients about the importance of gradual activity progression and pacing themselves.

6. Patient Education on Home Self-Care:

• Rationale: Empowering patients with knowledge about their condition and self-care strategies promotes adherence to treatment plans, improves outcomes, and prevents readmissions.
• Nursing Action: Provide comprehensive patient education on:
  • Disease process and pathophysiology of decreased cardiac output.
  • Medications: purpose, dosage, side effects, administration, adherence.
  • Diet: sodium restriction, fluid management, heart-healthy diet.
  • Activity: gradual progression, exercise guidelines, energy conservation.
  • Symptom recognition: warning signs of worsening condition (e.g., increased shortness of breath, chest pain, edema, weight gain).
  • When to seek medical attention.
  • Lifestyle modifications: smoking cessation, stress management, weight management.

7. Cardiac Monitoring:

• Rationale: Continuous cardiac monitoring allows for early detection and prompt management of arrhythmias, which are common and potentially life-threatening in patients with decreased cardiac output.
• Nursing Action: Maintain continuous ECG monitoring. Closely observe for arrhythmias. Be prepared to administer antiarrhythmic medications or implement other interventions as prescribed or per protocol.

8. Educate Patient to Avoid Valsalva Maneuvers:

• Rationale: Valsalva maneuvers (e.g., straining during bowel movements, holding breath during exertion) increase intrathoracic pressure, reducing venous return and cardiac output, and increasing cardiac workload.
• Nursing Action: Educate patients to avoid Valsalva maneuvers. Provide strategies to prevent constipation (e.g., stool softeners, adequate hydration, dietary fiber). Instruct patients to exhale during exertion.

9. Implement Rehabilitation Plan (PT/Cardiac Rehab):

• Rationale: Cardiac rehabilitation programs improve functional capacity, quality of life, and reduce mortality in patients with heart conditions, including decreased cardiac output. Physical therapy helps improve muscle strength and endurance.
• Nursing Action: Refer patients to cardiac rehabilitation programs and physical therapy as appropriate. Collaborate with rehabilitation specialists to ensure a coordinated and individualized plan of care.

10. Anticipate Potential for Deterioration and Cardiac Arrest:

• Rationale: Patients with decreased cardiac output are at increased risk for clinical deterioration and cardiac arrest. Early recognition of worsening signs and symptoms and prompt intervention are crucial.
• Nursing Action: Continuously monitor vital signs, level of consciousness, and symptoms. Be vigilant for signs of deterioration (e.g., worsening hypotension, altered mental status, increased anxiety, chest pain, severe shortness of breath). Alert the medical team promptly to any concerning changes. Be prepared to initiate resuscitation measures (CPR, defibrillation) if cardiac arrest occurs.

These nursing interventions are fundamental to the management of decreased cardiac output. Individualized care plans, guided by ongoing assessment and patient-specific needs, are essential to optimize outcomes.

Nursing Care Plans for Decreased Cardiac Output: Examples

Nursing care plans provide a structured framework for organizing and delivering patient care. Here are examples of nursing care plans for decreased cardiac output, focusing on different underlying causes and manifestations:

Care Plan #1: Decreased Cardiac Output related to Bundle Branch Block

Diagnostic Statement: Decreased cardiac output related to altered heart rate secondary to bundle branch block as evidenced by ECG changes and chest pain.

Expected Outcomes:

• Patient will demonstrate adequate cardiac output as evidenced by:
  • Heart rate 60-100 bpm.
  • Blood pressure 90-130/60-90 mmHg.
  • Regular sinus rhythm on ECG.
  • Absence of chest pain.
  • Absence of dyspnea.
• Patient will maintain baseline level of consciousness.

Assessment:

1. Monitor chest pain: Assess characteristics (precipitating/relieving factors, quality, radiation, severity, timing, location, associated symptoms).
   • Rationale: Chest pain may indicate myocardial ischemia, a cause of decreased cardiac output. Untreated DCO can lead to end-organ damage.
2. Monitor ECG findings: Evaluate ECG for bundle branch block and other abnormalities.
   • Rationale: Bundle branch block can indicate underlying myocardial degeneration and dysfunction, especially when associated with cardiac symptoms.

Interventions:

1. Instruct patient to relax during chest pain episodes:
   • Rationale: Relaxation reduces myocardial oxygen demand, restoring balance between oxygen supply and demand.
2. Administer sublingual nitroglycerin as prescribed: (e.g., every 5 minutes, max 3 doses).
   • Rationale: Nitroglycerin dilates coronary arteries, improving myocardial perfusion and relieving ischemic chest pain.
3. Administer oxygen as indicated:
   • Rationale: Supplemental oxygen increases arterial oxygen saturation and oxygen delivery to the heart muscle.
4. Educate patient on angina-provoking factors: (heavy meals, exertion, extreme temperatures, stress, stimulants).
   • Rationale: Patient education empowers self-management and reduces exposure to triggers that can worsen angina and decrease cardiac output.
5. Refer to cardiac rehabilitation program:
   • Rationale: Cardiac rehab provides education and supervised exercise, improving functional capacity, quality of life, and reducing mortality in patients with cardiac conditions.

Care Plan #2: Decreased Cardiac Output related to Atrial Fibrillation

Diagnostic Statement: Decreased cardiac output related to altered rhythm secondary to atrial fibrillation as evidenced by irregular pulse and dizziness.

Expected Outcomes:

• Patient will demonstrate adequate cardiac output as evidenced by:
  • Regular sinus rhythm (post-cardioversion or rate/rhythm control).
  • Strong, regular peripheral pulses.
  • Heart rate 60-100 bpm (if rate control strategy).
  • Blood pressure 90-130/60-90 mmHg.
• Patient will remain free from falls or injuries related to dizziness.

Assessment:

1. Initiate ECG monitoring:
   • Rationale: Atrial fibrillation increases risk of thromboembolism, stroke, and death. Continuous ECG monitoring is essential for assessing heart rate and rhythm and guiding management.
2. Monitor hemodynamic parameters: (pulmonary wedge pressure, systemic vascular resistance, stroke volume, cardiac output).
   • Rationale: In hemodynamically unstable patients, central hemodynamic monitoring may be necessary to assess for cardiogenic shock, a complication of atrial fibrillation.
3. Identify underlying cause of atrial fibrillation: Assess history, frequency/timing of episodes, cardiovascular history, medications.
   • Rationale: Identifying underlying causes guides treatment strategies and risk factor modification.

Interventions:

1. Position patient in semi- to high-Fowler’s position; administer oxygen:
   • Rationale: Promotes ventilation and perfusion, especially if patient is dyspneic or hypoxemic.
2. Prepare for cardioversion if hemodynamically unstable:
   • Rationale: Cardioversion (chemical or electrical) may be necessary to restore sinus rhythm and improve cardiac output in unstable patients.
3. Administer medications as ordered: (rate control, rhythm control, anticoagulants).
   • Rationale: Medications manage heart rate and rhythm, and prevent thromboembolic complications associated with atrial fibrillation.
4. Educate patient on lifestyle modifications:
   • Rationale: Lifestyle changes are crucial for managing atrial fibrillation and improving overall cardiac health.
     • Medication adherence: Emphasize importance of anticoagulation, if prescribed, and bleeding risks.
     • Diet: Vitamin K intake if on warfarin, avoid excessive alcohol/caffeine.
     • Smoking cessation: Nicotine is a cardiac stimulant.
     • Stress reduction: Stress can trigger atrial fibrillation.
     • OTC medications: Avoid stimulants in cold remedies, nasal sprays.
5. Refer to community resources: (education, support, activity guidance).
   • Rationale: Multidisciplinary support improves outcomes and quality of life for patients with atrial fibrillation, a complex chronic condition.

Care Plan #3: Decreased Cardiac Output related to Altered Preload

Diagnostic Statement: Decreased cardiac output related to altered preload as evidenced by anxiety and altered blood pressure.

Expected Outcomes:

• Patient will demonstrate adequate cardiac output as evidenced by:
  • Stable blood pressure, pulse rate, and rhythm.
  • Strong peripheral pulses.
  • No deterioration in level of consciousness.
  • Absence of chest pain and dyspnea.
  • Adequate urinary output.
• Patient will explain actions and precautions to prevent primary or secondary cardiac disease.

Assessment:

1. Monitor and report symptoms: (dyspnea, orthopnea, paroxysmal nocturnal dyspnea, cough, abdominal distention, fatigue, weakness).
   • Rationale: These symptoms are consistent with heart failure and decreased cardiac output, reflecting fluid overload and impaired perfusion.
2. Monitor vital signs and LOC closely:
   • Rationale: Changes in blood pressure and anxiety may indicate acute cardiac event and decompensation, requiring frequent assessment and potential escalation of care.
3. Monitor intake and output hourly (acute conditions): Note oliguria/anuria.
   • Rationale: Decreased cardiac output reduces renal perfusion, leading to oliguria. I&O monitoring tracks treatment response and fluid balance.

Interventions:

1. Position patient in semi- to high-Fowler’s with legs dependent or in position of comfort:
   • Rationale: Head elevation eases breathing; dependent leg position may decrease venous return and preload.
2. Obtain ECG and stat blood work if acute cardiac event suspected:
   • Rationale: Rapid assessment is crucial if acute decompensation is suspected, allowing for prompt diagnosis and intervention.
3. Provide restful environment: Minimize stressors, unnecessary disturbances.
   • Rationale: Reducing stressors decreases cardiac workload and oxygen demand.
4. Teach types and progression of worsening heart failure symptoms:
   • Rationale: Patient/family education enables early recognition of worsening condition, prompting timely medical attention and preventing complications.

These care plan examples illustrate the individualized approach to nursing care for decreased cardiac output. Nurses utilize these plans as guides, tailoring interventions to the specific patient presentation and constantly evaluating and adjusting care based on patient response and ongoing assessment.

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