DECREASED CARDIAC OUTPUT

ASSESSMENT

DIAGNOSIS

SCIENTIIC BACKGROUND . Hypertension

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

Subjective Data: Pakiramdam ko ang bilis-bilis ng tibok ng puso ko. Tapos kapag nagpa-BP ako, mataas pala BP ko. As verbalized by the patient. Objective Data: Body weakness Pallor Variations in hemodynami c parameters such as: blood pressure of 150/100 mmHg and heart rate of 115 bpm Arrhythmia

Decreased Cardiac Output related to cardiac arrhythmia secondary to Hypertension

cause the heart muscle to get thick and stiff

Short Term goal: After rendering nursing intervention, the patient will be able to:

INDEPENDENT NURSING ACTION: Monitored and measured blood pressure in both hands, using a cuff and proper techniques in terms of measuring blood pressure Observed skin color, moisture, temperature, and capillary refill time Comparison of pressures provides a more complete picture of vascular involvement/sc ope of problem Presence of pallor; cool, moist skin; and delayed capillary refill time may be due to peripheral vasoconstrictio n or reflect cardiac decompensatio n/decreased output

so that it does not relax and fill up with blood properly

Participate in activities that reduce BP/cardiac workload Maintain BP within individually acceptable range stable cardiac rhythm and rate within patients normal range

Goal met. After rendering nursing intervention the patient maintained her blood pressure within acceptable range as evidenced by reduction of blood pressure from 150/100 mmHg to 130/90

Arrhythmia

Demonstrate

Decreased Cardiac Output

Noted presence, quality of central and peripheral pulses

Pulses in the legs/feet may be diminished, reflecting effects of vasoconstrictio n (increased systemic