- Decreased Cardiac Output related to Decreased peripheral vascular resistance and decreased vessel wall flexibility as evidenced by decreased blood pressure, less than normal limits and dizziness or light-headedness
- Impaired Gas Exchange related to Incomplete filling of the heart during heart contraction and ventilation-perfusion imbalance as evidenced by Difficulty of breathing and Nasal flaring
- Ineffective Tissue Perfusion related to Inadequate blood pressure and poorly oxygenated blood as evidenced by decreased blood pressure (hypotension) and cold and clammy skin
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Verbalizes tightening of chest Objective data: -Bradycardia -Decreased blood volume -Blurred vision -Dizziness or light-headedness -Fainting -Fatigue -Trouble concentrating -Low urine output | Decreased Cardiac Output related to Decreased peripheral vascular resistance and decreased vessel wall flexibility as evidenced by decreased blood pressure, less than normal limits and dizziness or light-headedness | Patient will maintain blood pressure within normal limits. Patient will verbalize the relationship between cardiac output and blood pressure. Patient will participate in preventive activities that decrease the workload of the heart and hypotension | 1. Position the patient comfortably. A semi-Fowler’s position is recommended to aid cardiac compensation and reduce oxygen consumption. 2. Administer oxygen as ordered. Oxygen administration increases the oxygen available for heart function and tissue perfusion. 3. Administer medications as ordered. Inotropic medications increase cardiac contractions to help systemic and cardiac circulation. 4. Monitor intake and output. If blood pressure is low, there may not be enough blood to support kidney function. Low urine output can signal issues with perfusion. 5. Administer IV fluids and/or blood. Low circulating blood volumes are a major contributor to hypotension. Ensure adequate volume by administering IV fluids and replacing blood or plasma. | Patient maintained blood pressure within normal limits. Patient verbalized the relationship between cardiac output and blood pressure. Patient participated in preventive activities that decrease the workload of the heart and hypotension |
| Subjective data: -Dyspnoea -Diaphoresis (excessive sweating) -Headaches Objective data: -Altered respiratory patterns -Restlessness -Lethargy -Cyanosis -Confusion -Irritability -Impending sense of doom -Increased heart rate -Decreased oxygen saturation | Impaired Gas Exchange related to Incomplete filling of the heart during heart contraction and ventilation-perfusion imbalance as evidenced by Difficulty of breathing and Nasal flaring | Patient will demonstrate ABGs within normal limits. Patient will maintain oxygen saturation and breathing pattern within normal limits. Patient will verbalize no complaints of difficulty breathing, nasal flaring, or restlessness. | 1. Perform continuous telemetry and spo2 monitoring. The body is at risk of not obtaining enough oxygen to perform its function if the blood pressure falls dangerously low. Reduced oxygen levels can affect the gas exchange in the heart and lungs. 2. Prevent hypotensive shock. A significant drop in blood pressure (shock) can be fatal, including those brought on by uncontrolled bleeding, severe infections, or allergic responses. Prevent this by ensuring adequate volume expansion through IV fluids, blood products, and medications. 3. Promote coughing and breathing techniques. Show the patient how to breathe and cough therapeutically. Coughing and deep breathing increase air exchange and oxygenation. Deep diaphragmatic breathing aids blood flow into the heart and the lungs for gas exchange. 4. Check ABGs within an hour after starting oxygen therapy. ABGs should be checked 30-60 minutes after starting oxygen to ensure oxygenation without CO2 retention. | Patient demonstrated ABGs within normal limits. Patient maintained oxygen saturation and breathing pattern within normal limits. Patient verbalized no complaints of difficulty breathing, nasal flaring, or restlessness. |
| Subjective data: -Chest Pain -Dyspnoea -Sense of impending doom 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 Inadequate blood pressure and poorly oxygenated blood as evidenced by decreased blood pressure (hypotension) and cold and clammy skin | Patient will maintain peripheral pulses and capillary refill time within acceptable limits. Patient will present an alert, conscious, and coherent level of consciousness. Patient will verbalize no complaints of dizziness or fainting. | 1. Improve blood flow. Fludrocortisone and midodrine improve blood pressure and tissue perfusion. Fludrocortisone increases blood volume to increase tissue perfusion, while midodrine raises the blood pressure with chronic orthostatic hypotension. 2. Encourage the patient to wear anti-embolic stockings. Anti embolic or compression stockings lower varicose vein discomfort and edema to improve blood flow of the lower extremities. 3. Promote salt intake. Promote salt (sodium) in the patient’s diet, which can significantly increase blood pressure and tissue perfusion. Sodium intake can be beneficial for those with low blood pressure. 4. Assist the patient in position changes. Encourage the patient to gently rise to a standing position from a supine or sitting position. When getting out of bed, advise the patient to dangle on the side of the bed before standing to prevent orthostatic hypotension. 5. Prepare the patient for a tilt table test. A tilt table test can gauge how the body responds to positional changes. Throughout the exam, blood pressure and heart rate are tracked. | Patient maintained peripheral pulses and capillary refill time within acceptable limits. Patient presented alert, conscious, and coherent level of consciousness. Patient verbalized no complaints of dizziness or fainting. |