- Ineffective Peripheral Tissue Perfusion
Related to Decreased cardiac output as evidenced by decreased peripheral pulses,
Generalized weakness and Dyspnoea - (Risk for) Decreased Cardiac Output related to Decreased heart rate and Altered heart rhythm as evidenced by Hypotension and Dysrhythmias
- Deficient Knowledge related to Inadequate access to accurate healthcare information and Inadequate knowledge of resources as evidenced by Inaccurate follow-through of instructions and Development of complications
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Chest Pain Dyspnea Sense of impending doom Objective data: Arrhythmias Capillary refill >3 seconds Abnormal arterial blood gases Unstable blood pressure Tachycardia or bradycardia Cyanosis | Ineffective Peripheral Tissue Perfusion Related to Decreased cardiac output as evidenced by decreased peripheral pulses, Generalized weakness and Dyspnoea | Patient will demonstrate adequate tissue perfusion with warm extremities, palpable peripheral pulses, and blood pressure within acceptable limits. Patient will remain alert and oriented without confusion or dizziness. | 1. Encourage the patient to wear compression stockings while ambulating. Compression stockings can help increase venous return and promote peripheral circulation. 2. Administer medications as indicated. Symptomatic bradycardia may require atropine, epinephrine, or dopamine to increase the heart rate. 3. Treat electrolyte imbalances. If bradycardia is caused by hyper or hypokalemia, medications can help increase or lower the electrolyte. 4. Assist with testing. A tilt table test assesses if the patient is predisposed to fainting or syncope with position changes. A stress exercise test measures the heart’s activity during exercise | Patient demonstrated adequate tissue perfusion with warm extremities, palpable peripheral pulses, and blood pressure within acceptable limits. Patient remained alert and oriented without confusion or dizziness. |
| Subjective Data: Verbalizes shortness of breath Objective Data: -Chest pain -Difficulty breathing -Rapid breathing -Alteration in the level of consciousness -Restlessness -Fatigue -Activity intolerance -Cold and clammy skin -Prolonged capillary refill time | (Risk for) Decreased Cardiac Output related to Decreased heart rate and Altered heart rhythm as evidenced by Hypotension and Dysrhythmias | Patient will demonstrate adequate cardiac output with blood pressure and heart rate within normal limits. Patient will demonstrate normal sinus rhythm on EKG. Patient will be able to tolerate activities without chest pain, dyspnoea, or changes in the level of consciousness. Patient will not experience complications of bradycardia and decreased cardiac output, such as heart failure. | 1. Perform continuous telemetry monitoring. For safe assessment, the client with a cardiac history or symptomatic bradycardia should be connected to continuous telemetry monitoring. 2. Monitor the use of sedatives. Carefully administer opioid analgesia, sedatives, and benzodiazepines, as these medications can further reduce the heart rate and cause respiratory depression. 3. Administer supplemental oxygenation. Emergency cardiovascular care includes supplemental oxygenation for respiratory distress associated with decreased cardiac output and bradycardia. 4. Instruct on the use of a Holter monitor or an event recorder. A Holter monitor is a wearable device that records the heart rate and rhythm to detect abnormalities when the patient is experiencing symptoms like chest pain, dizziness, and dyspnoea to help pinpoint the cause and assist with treatment planning. An event recorder is similar but isn’t worn at all times. 5. Administer medications as ordered. For patients with bradycardia who are hemodynamically unstable, push 0.5 mg of atropine intravenously (IV) every 3 to 5 minutes, up to a maximum dose of 3 mg as prescribed. 6. Prepare for pacemaker insertion. A pacemaker is implanted in the chest to control the heart rate and prevent bradycardia. The nurse assists with preparing the patient prior to surgery, monitoring for complications post-op, and providing discharge instructions. | Patient demonstrated adequate cardiac output with blood pressure and heart rate within normal limits. Patient demonstrated normal sinus rhythm on EKG. Patient will be able to tolerate activities without chest pain, dyspnoea, or changes in the level of consciousness. Patient relieved from complications of bradycardia and decreased cardiac output, such as heart failure. |
| Subjective Data: Verbalizes unable to follow through the treatment process Objective Data: -Inaccurate statements about bradycardia -Poor adherence to wearing a Holter monitor | Deficient Knowledge related to Inadequate access to accurate healthcare information and Inadequate knowledge of resources as evidenced by Inaccurate follow-through of instructions and Development of complications | Patient will verbalize lifestyle modifications to prevent bradycardia. Patient will verbalize the symptoms and complications of bradycardia. | 1. Teach the patient how to monitor their pulse. Devices such as a pulse oximeter can quickly assess the heart rate, but the patient can also be taught how to count their radial pulse. 2. Teach symptoms related to bradycardia. Not all patients will experience symptoms of a slow heart rate. Ensure the patient understands that symptoms of dizziness, chest pain, shortness of breath, and exercise intolerance should be reported to their healthcare provider. 3. Encourage the patient to quit smoking and limit alcohol use. A healthier lifestyle can reduce the risk of developing bradycardia and other complications. 4. Refer the patient to a cardiologist. The patient with symptomatic bradycardia should receive follow-up care from a cardiologist. | Patient verbalized lifestyle modifications to prevent bradycardia. Patient verbalized the symptoms and complications of bradycardia. |