Assessment

Subjective:
(no
verbalization:
client is
unresponsive
upon
admission)
Clients
daughter
reports that
patient was
experiencing
chest pain for
the past 2
weeks &
claudication
of lower
extremities.
Objective:
Pupillary
reflex (+) 23mm equally
reactive
BP 210/80
CR 124
irregular
RR 24/min,
labored
Distended

Nursing
Diagnosi
s
Decrease
d cardiac
output
related to
reduced
preload.

Scientific
Analysis

Goals/Objectiv
es

Due to
occulusion
of
coronary,
blood
supply is
cut off to
the
vasculature
above the
occlusion.
The heart
fails to
receive
adequate
oxygen and
as a
compensati
on
mechanism
continues
to pump
blood
throughout
by
increasing
cardiac
contractilit
y and rate

After 5 hours of
nursing
intervention, the
client will:
Display
hemodynamic
stability as
manifested by
stable blood
pressure
(140/80).
Report/
demonstrate
decrease
episodes of
dyspnea,
angina, and
dysrhythmias.
Verbalize
knowledge of
the disease
process,
individual risk
factors, and
treatment
plan.
Demonstrate
an increase in
activity

Interventions

Rationale

Decreased cardiac
output results in
diminished weak or
thready pulses.
Evaluate quality of
Irregularities
pulses on both
suggest
pulse points.
dysrhythmias,
which may require
further evaluation
and monitoring.
Ascultate heart sounds for:
S3 is usually
associated with HF,
but it may also be
noted with the
Note development
mitral insufficiency
of S3
(regurgitation) and
left ventricular
overload that can
accompany severe
infarction.
S4
S4 may be
associated with
myocardial
ischemia,
ventricular
stiffening, and
pulmonary or
systemic
hypertension.

Evaluation
After 5 hours of
nursing
intervention, the
client:
Displayed
hemodynamic
stability as
manifested by
stable blood
pressure
(140/80).
Reported/
demonstrated
decrease
episodes of
dyspnea,
angina, and
dysrhythmias.
Verbalized
knowledge of
the disease
process,
individual risk
factors, and
treatment
plan.
Demonstrated
an increase in
activity

neck veins
(+) Bruit
carotid artery
R.
(+) bibasilar
crackles BLF
Dynamic
precordium
AB 6th LICS
AAL
(+) systolic
blowing
murmur at
the apex
high pitched
blowing
murmur at
the 3rd ICS
left sternal
boarder
(+) pulsating
mass at the
xiphoid area
(+++) pulse
on the radial
(+) pulse on
the dorsalis
pedis
(++) Pulse on
the popliteal
and femoral

and
eventually
ischemia
occurs.

tolerance and
participate in
activities that
reduce cardiac
workload such
as therapeutic
medication
regimen,
balance
activity/rest
plan, proper
use of
supplemental
O2.

Auscultate breath
sounds.

Monitor and
document heart
rate and rhythm.
Report any
significant findings
to attending
physician.

Crackles reflecting
pulmonary
congestion may
develop because of
depressed
myocardial
function.
Heart rate and
rhythm respond to
medication,
activity, and
developing
complications.
Dysrhythmias
(especially
premature
ventricular
contractions or
progressive heart
blocks) can
compromise
cardiac function or
increase ischemic
damage. Acute or
chronic atrial flutter
may be seen with
coronary artery or
valvular
involvement and
may or may not be
pathological.

tolerance and
participated in
activities that
reduce cardiac
workload such
as therapeutic
medication
regimen,
balance
activity/rest
plan, proper
use of
supplemental
O2.

artery.
Administer
supplemental
oxygen, as
indicated.

Have emergency
equipment and/or
medications
available bedside.

Administer
antidysrhythmic
drugs as indicated.

Increases amount
of oxygen available
for myocardial
uptake, reducing
ischemia and
resultant cellular
irritation and/or
dysrhythmias.
Sudden coronary
occlusion, lethal
dysrhythmias,
extension of infarct,
and unrelenting
pain are situations
that may
precipitate cardiac
arrest, requiring
immediate lifesaving therapies
and/or transfer to
CCU.
Dysrhythmias are
usually treated
symptomatically,
except for PVCs,
which are often
treated
prophylactically.
Early inclusion of
ACE inhibitor
therapy (especially
in presence of large
anterior MI,
ventricular

Review serial ECGs.

Review chest x-ray.

Monitor laboratory
data: cardiac
enzymes, ABGs,
electrolytes.

aneurysm, or HF)
enhances
ventricular output,
increases survival,
and may slow
progression of HF.
Provides
information
regarding
progression or
resolution of
infarction, status of
ventricular
function,
electrolyte balance,
and effects of drug
therapies.
May reflect
pulmonary edema
related to
ventricular
dysfunction.
Enzymes monitor
resolution or
extension of
infarction. Presence
of hypoxia
indicates need for
supplemental
oxygen. Electrolyte
imbalances:
hypokalemia or
hyperkalemia,
adversely affects

cardiac rhythm and

contractility.

Note presence of
pulsus paradoxus,
especially in the
presence of distant
heart sounds.

Note response to
activity and
promote rest
appropriately.

Pulsus
paradoxus (PP),
also paradoxic
pulse or
paradoxical pulse,
is an abnormally
large decrease in
systolic blood
pressure and pulse
wave amplitude
during inspiration.
The normal fall in
pressure is less
than 10 mmHg or
10 torr. When the
drop is more than
10mm Hg, it is
referred to
as pulsus
paradoxus.
Suggestive of
cardiac tamponade.
Overexertion
increases oxygen
consumption and
demand and can
compromise
myocardial
function.

Keep client on
semi-Fowlers
position.
Decrease stimuli,
provide quiet
environment.
Administer
analgesics as
ordered.

Provide information
about medical
procedures
performed and
client participation.

Decreases oxygen
compensation and
risk of
decompensation.
To promote
adequate rest; this
reduces oxygen
consumption.
To promote comfort
and rest, and
reduce pain caused
by angina.
Maintains calm
attitude and
reassures client
that the medical
procedure to be
performed is of
little to no harm.
Reduces anxiety.