ASSESSMENT

EXPLANATION OF THE PROBLEM The ECG result of the client shows a Sinus Bradycardia in which the impulse originating from the sinoatrial node has a slow rate thus it creates a slower heart rate than normal leading to decreased cardiac output. Decreased cardiac output is evident in the client because she has a slow HR which is 60 bpm, she was easily exhausted from doing normal activities in life. Though the client is acyanotic. She has a pinkish palpebral conjunctiva and a capillary refill of 1- 2 seconds.

GOALS AND OBJECTIVES LTO> After 72 hours of nursing intervention, the client will demonstrate: increased HR from 60 bpm to 80 bpm Regular rhythm of the heart by ECG No more episodes of angina Able to do normal activities without any difficulty STO> After 8 hours of nursing interventions, the client will be demonstrate: Increased HR from 60 bpm to 70 bpm Increased activity tolerance with minimal exhaustion as manifested by slight increase in VS

INTERVENTIONS

RATIONALE

EVALUATION

S> Madali ako mapagod. Tapos bumibigat ang dibdib ko di ako makahinga. Minsan sumasakit pa ang dibdib ko. O> with abnormal ECG result revealing Sinus Bradycardia; with HR of 60 bpms regular; increased VS after activity such as going to the CR; with capillary refill of 1-2 seconds;with pinkish palpebral conjunctiva; acyanotic; A > Decreased Cardiac Output related to altered cardiac rhythm

Assess mentation.

Increasing lethargy, confusion, restlessness and / or irritability can be early signs of cerebral hypoxia from decreased cardiac output Increased respiratory rate and use of accessory muscles may be seen in patients with hypoxia

Assess patient respirations by observing respiratory rate and depth and use of accessory muscles

Observe patient for restlessness, agitation, confusion and (late stages) lethargy

Changes in behavior and mental status can be early signs of impaired gas exchange which will result from decreased cardiac output

 Assess patient for chest pain or discomfort noting location, severity, duration, quality and radiation

Chest pain is generally indicative of inadequate blood supply to the heart which can result in decreased cardiac output Pallor or cyanosis, cool moist skin and slow capillary refill time may be present from peripheral vasoconstriction and decreased oxygen saturation Weak, thready peripheral pulses may reflect hypotension, vasoconstriction, shunting and venous congestion Heart irritability is common with conduction defects and/or ischemia from a poorly

Observe patient for changes in skin color, moisture, temperature and capillary refill time

Assess peripheral pulses

Monitor patient for changes in heart rate and/or rhythm

perfused heart Monitor hourly urine output Decreased cardiac output results in decreased perfusion to the kidneys and decreased urine output. Urinary output < 30 ml/hr. indicates inadequate renal perfusion Rest and a quiet environment reduces a catecholamineinduced stress response and decreases cardiac workload thus increasing cardiac output Decreases oxygen consumption and risk for decompensation

Promote rest

Keep client on bed or chair in position of comfort. Semifowlers position preferably. Assist when performing self-

To facilitate the self-care and

care activities.

reduce the stress and exhaustion felt by the client when doing so. Patient is often on multiple medications which can be difficult to manage, thus increasing the likelihood that medications can be missed or incorrectly used

Educate patient and caregivers about the importance of taking prescribed medications at prescribed times