- Electrolyte Imbalance related to Changes in the regulation of potassium and Conditions that affect the movement of potassium in the cellular space as evidenced by Alterations in the electrical conductivity of the heart and Changes in bowel habits
- Ineffective Tissue Perfusion related to Alteration in serum potassium level and Insufficient knowledge of hypokalaemia/hyperkalaemia and its management as evidenced by Muscle weakness and Diminished reflexes
- Risk for Decreased Cardiac Output related to changes in the conductivity in the heart and inability to pump blood effectively as evidenced by abnormal blood pressure, heart rate, and rhythm
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Objective Data: Verbalizes increased heartbeat and edema Objective Data: -Alterations in the electrical conductivity of the heart -Ineffective respirations -Muscle weakness and cramps -Neuromuscular alterations -Changes in bowel habits | Electrolyte Imbalance related to Changes in the regulation of potassium and Conditions that affect the movement of potassium in the cellular space as evidenced by Alterations in the electrical conductivity of the heart and Changes in bowel habits | Patient will maintain normal electrolyte levels (serum potassium, sodium, calcium, magnesium, and phosphorus). Patient will maintain normal fluid balance. Patient will maintain adequate hydration. Patient will maintain normal kidney function. Patient will maintain normal sinus rhythm. Patient will have decrease/absent edema. Patient will verbalize understanding of nutritional status and ways to maintain normal electrolyte levels. | 1. Weigh the patient daily. Regular monitoring of the patient’s weight will indicate if there is fluid volume excess, which could cause changes in electrolyte levels. 2. Administer pain medication as appropriate. Electrolyte abnormalities may cause discomfort, and patients may need treatment for pain. 3. Provide intravenous or oral hydration as needed. Patients are more prone to electrolyte imbalances when experiencing vomiting and/or diarrhea. It is important that the nurse ensures the patient is maintaining appropriate hydration status. 4. Supplement electrolyte levels as appropriate as ordered by the healthcare provider. If patients’ electrolyte levels are low, additional supplements may be needed orally or intravenously to maintain appropriate levels. The nurse will administer these as ordered by the healthcare provider. 5. Administer oxygen as needed. Electrolyte imbalances can cause respiratory distress/failure. The nurse should monitor closely and if needed, supply supplemental oxygen therapy. 6. Educate patient and family on signs and symptoms of electrolyte abnormalities. This will help to provide the patient with more independence at home in managing their care and preventing further complications or episodes of electrolyte abnormalities. 7. Educate the patient and family members on the importance of a balanced diet and the importance of hydration. This will help patients to understand how their nutritional status affects their electrolyte levels. 8. Educate the patient and family members on the importance of taking medications as prescribed and what their specific medications are used for. Understanding their individualized medication regimen will help the patient to develop more independence in their care. Adherence to medication regimens will also reduce the chances of electrolyte imbalances precipitated by worsening disease. | Patient maintained normal electrolyte levels (serum potassium, sodium, calcium, magnesium, and phosphorus). Patient maintained normal fluid balance. Patient maintained normal kidney function. Patient maintained normal sinus rhythm Patient has decreased edema. Patient verbalized understanding of nutritional status and ways to maintain normal electrolyte levels. |
Subjective data: Chest Pain Dyspnea Objective data: -Arrhythmias -Capillary refill >3 seconds -Altered respiratory rate -Use of accessory muscles to breathe -Abnormal arterial blood gases -Unstable blood pressure -Tachycardia or bradycardia -Cyanosis | Ineffective Tissue Perfusion related to Alteration in serum potassium level and Insufficient knowledge of hypokalaemia/hyperkalaemia and its management as evidenced by Muscle weakness and Diminished reflexes | Patient will maintain adequate peripheral perfusion as evidenced by strong pedal pulses, warm skin temperature, and intact skin without edema. Patient will maintain cardiopulmonary perfusion as evidenced by normal sinus heart rhythm, heart rate within normal limits, no complaints of shortness of breath and normal Sa02. Patient will demonstrate appropriate lifestyle modifications to support adequate tissue perfusion. Patient will have an improvement in cerebral perfusion as evidenced by intact orientation to person, place, and time. | 1. Administer medications to improve blood flow as ordered. Vasodilators open blood vessels to improve blood flow such as nitroglycerin for chest pain, or hydralazine for high blood pressure. 2. Provide oxygen as required. To support oxygenation and perfusion oxygen may be needed to ensure gas exchange. 3. Surgical Intervention. Conditions that impede blood flow, such as blockages may require coronary angioplasty or bypass surgeries. The nurse is vital in educating the patient and family on procedures and monitoring for complications post-op. 4. Teach signs of a heart attack. Symptoms of a heart attack are different for males and females. Males may have direct chest pain while females often have indirect symptoms such as nausea and jaw, back, or arm pain | Patient maintained adequate peripheral perfusion as evidenced by strong pedal pulses, warm skin temperature, and intact skin without edema. Patient maintained cardiopulmonary perfusion as evidenced by normal sinus heart rhythm, heart rate within normal limits, no complaints of shortness of breath and normal Sa02. Patient demonstrated appropriate lifestyle modifications to support adequate tissue perfusion. Patient has an improved in cerebral perfusion as evidenced by intact orientation to person, place, and time. |
| Subjective Data: Verbalizes tiredness and fatigue Objective Data: -Abnormal blood pressure, heart rate, and rhythm -Abnormal ABG Values | Risk for Decreased Cardiac Output related to changes in the conductivity in the heart and inability to pump blood effectively as evidenced by abnormal blood pressure, heart rate, and rhythm | Patient will show adequate cardiac output as evidenced by blood pressure, heart rate, and rhythm within normal limits. Patient will be able to return to baseline activity level. Patient will display adequate breathing as evidenced by appropriate oxygen saturation level and absence of adventitious breath sounds. Patient will be able to verbalize future self-care activities to improve cardiac health. | 1. Administer supplemental oxygen as needed. Patient’s oxygen saturation may be low and may require supplemental oxygen in order to maintain appropriate levels. Appropriate oxygenation is necessary to improve overall condition and bodily functions. 2. Administer prescribed medications as ordered. Various medications may be ordered for patients with decreased cardiac output (i.e. ACE, ARBs, etc.). These will help to improve heart function and decrease patient’s symptoms and cardiac workload. 3. Elevate the head of the bed. Elevating the head of the bed will allow the patient better positioning for breathing and be able to maintain an appropriate oxygenation level. 4. Maintain fluid restriction and/or sodium restriction. Patients with low cardiac output are more prone to retaining additional fluids and can be very sensitive to sodium. A fluid and/or sodium restriction may be necessary to minimize fluid retention. 5. Initially allow for bedrest during acute phase. As the patient’s status improves, slowly begin activity to increase tolerance and stamina. Patients with decreased cardiac output can become deconditioned quickly. Initially, bedrest is warranted until the patient is able to reach a stable cardiac and respiratory state. Once stable, slowly increasing activity level will help to strengthen muscles including cardiac muscles. 6. Educate the patient on home self-care. Providing education for patients will allow them to understand the pathophysiology of what is occurring in regard to their health. Education will also assist patients in understanding measures they can take at home to improve their cardiac health and prevent further deterioration. 7. Place the patient on a cardiac monitor. Cardiac arrhythmias are common with decreased cardiac output. It is important to be able to monitor for these and then treat as appropriate should an arrhythmia develop. 8. Educate patient to avoid Valsalva maneuvers. These maneuvers can put extra strain on the cardiac muscle. 9. Implement a rehabilitation plan for activity (PT and/or cardiac rehab). These types of programs can improve the patient’s quality of life and decrease mortality. 10. Anticipate potential for deterioration. Patients who have decreased cardiac output may be at risk of cardiac arrest. | Patient shown adequate cardiac output as evidenced by blood pressure, heart rate, and rhythm within normal limits. Patient returned to baseline activity level. Patient displayed adequate breathing as evidenced by appropriate oxygen saturation level and absence of adventitious breath sounds. Patient verbalized future self-care activities to improve cardiac health. |