- Activity Intolerance related to the imbalance between oxygen supply/demand and generalized weakness as evidenced by abnormal blood pressure response to activity and abnormal heart rate response to activity, exertional dyspnoea
- Decreased Cardiac Output Related to altered heart rate and contractility and Inflammation of cardiac muscles as evidenced by Heart palpitations and Dyspnoea upon exertion
- Impaired Gas Exchange Related to lack of oxygenated blood and ineffective heart muscle contraction as evidenced by Dyspnoea and Reduced ejection fraction
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Patient’s report of decreased activity/weakness -Shortness of breath with exertion -Fatigue -Exertional discomfort Objective data: -Abnormal blood pressure and heart rate response to activity -Changes to ECG -Signs of pain with movement/activity -Difficulty engaging in activity Increased oxygen demands | Activity Intolerance related to the imbalance between oxygen supply/demand and generalized weakness as evidenced by abnormal blood pressure response to activity and abnormal heart rate response to activity, exertional dyspnoea | Patient will be able to increase their activity level to perform desired activities. Patient will demonstrate the ability to climb one flight of stairs without dyspnea. | 1. Assist in self-care while promoting independence when tolerated. Providing care to the patient ensures that the patient’s needs are met while reducing efforts that compromise cardiac workload. Encouraging participation in self-care activities if tolerated allows the patient to maintain a sense of control and independence. 2. Schedule interventions with rest periods in between. Scheduling interventions and procedures with rest periods ensures that the patient’s needs are met without increasing oxygen demand and cardiac workload. 3. Monitor for an increasing incidence of activity intolerance. Increasing activity intolerance may indicate increasing cardiac decompensation. 4. Encourage the patient to adhere to a graded cardiac rehabilitation program. Patients with cardiomyopathy have irreversible cardiac dysfunction. Adhering to a graded cardiac rehabilitation program can help strengthen cardiac function without overexertion. | Patient will be able to increase their activity level to perform desired activities. Patient will demonstrate the ability to climb one flight of stairs without dyspnoea. |
| Subjective Data:’ -Dyspnoea -Chest Pain -Palpitations -Edema -Weakness -Anxiety and Restlessness Objective Data: -Jugular Venous Distension (JVD) -Dyspnoea upon exertion | Decreased Cardiac Output Related to altered heart rate and contractility and Inflammation of cardiac muscles as evidenced by Heart palpitations and Dyspnoea upon exertion | Patient will demonstrate adequate cardiac output with blood pressure and heart rate within normal limits. Patient will report reduced feelings of dyspnoea and angina. | 1. Encourage the patient to rest. Rest is essential to improve the efficiency of cardiac contractility and decrease myocardial workload by decreasing oxygen consumption. 2. Provide supplemental oxygen. Supplemental oxygenation increases oxygen availability for myocardial uptake to prevent hypoxia in patients with cardiomyopathy. 3. Administer medications as indicated. Medications such as antidysrhythmic, vasopressors, and diuretics can help control the progression of reduced cardiac output. 4. Prepare for pacemaker insertion. A pacemaker may be required to keep the heart beating in a regular rhythm. The nurse can instruct the patient on precautions following the procedure. | Patient demonstrated adequate cardiac output with blood pressure and heart rate within normal limits. Patient reported reduced feelings of dyspnoea and angina. |
| Subjective data: -Dyspnoea -Diaphoresis (excessive sweating) -Visual disturbances -Headaches Objective data: -Altered respiratory patterns -Restlessness -Lethargy -Cyanosis -Confusion -Irritability -Impending sense of doom -Abnormal arterial blood gas values or blood pH -Decreased oxygen saturation | Impaired Gas Exchange Related to lack of oxygenated blood and ineffective heart muscle contraction as evidenced by Dyspnoea and Reduced ejection fraction | Patient will display oxygen saturation > 95% and breathing pattern within normal limits. Patient will perform ADLs without dyspnoea or excessive fatigue. Patient will maintain an ejection fraction > 40%. | 1. Track the vital signs. Monitor the heart rate, blood pressure, SpO2, and cardiac rhythm. Hypoxemia can result in fluctuations in blood pressure, heart rate, decreasing oxygen saturation, and fatal dysrhythmias. 2. Administer oxygen as ordered. Increased oxygen delivery to the cardiac muscle helps the heart contract effectively. This aids in the gas exchange process. 3. Ask the patient to demonstrate pursed-lip breathing. Pursed-lip breathing helps the patient slow their respirations and release trapped air and CO2. 4. Remove fluid from the lungs. Cardiomyopathies such as congestive heart failure cause fluid to back up in the lungs from inadequate heart contraction, causing dyspnea and ineffective gas exchange. Diuretics can be administered IV or orally to rid the body of fluid. 5. Teach the patient when to seek medical help. Encourage the patient to seek emergency medical assistance if they experience signs of heart failure and complications of poor gas exchange. | Patient displayed oxygen saturation > 95% and breathing pattern within normal limits. Patient performed ADLs without dyspnoea or excessive fatigue. Patient maintained an ejection fraction > 40%. |