Nursing Diagnosis for Dysrhythmias | Decreased Cardiac Output

Nursing care plan | NCP Dysrhythmias

Risk factors may include

Altered electrical conduction

Reduced myocardial contractility

Possibly evidenced by

(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Cardiac Pump Effectiveness

Maintain or achieve adequate cardiac output as evidenced by BP and pulse within normal range, adequate urinary output, palpable pulses of equal quality, and usual level of mentation.

Display reduced frequency or absence of dysrhythmia(s).

Participate in activities that reduce myocardial workload.

Nursing care plan intervention with rationale:

1. Palpate radial, carotid, femoral, and dorsalis pedis pulses, noting rate, regularity, amplitude (full or thready), and symmetry. Document presence of pulsus alternans, bigeminal pulse, or pulse deficit.

Rationale:Differences in equality, rate, and regularity of pulses are indicative of the effect of altered cardiac output on systemic and peripheral circulation.

2. Auscultate heart sounds, noting rate, rhythm, presence of Specific dysrhythmias are more clearly detected audibly than by palpation.

Rationale: Specific dysrhythmias are more clearly detected audibly than by palpation. Hearing extra heartbeats or dropped beats helps identify dysrhythmias in the unmonitored client.

3. Monitor vital signs. Assess adequacy of cardiac output and tissue perfusion, noting significant variations in BP, pulse rate equality, respirations, changes in skin color and temperature, level of consciousness and sensorium, and urine output during episodes of dysrhythmias.

Rationale: Although not all dysrhythmias are life-threatening, immediate treatment may be required to terminate dysrhythmia in the presence of alterations in cardiac output and tissue perfusion.

4. Provide calm and quiet environment. Review reasons for limitation of activities during acute phase.

Rationale: Reduces stimulation and release of stress-related catecholamines, which can cause or aggravate dysrhythmias and vasoconstriction, increasing myocardial workload.

5. Demonstrate and encourage use of stress management behaviors such as relaxation techniques; guided imagery; and slow, deep breathing.

Rationale: Promotes client participation in exerting some sense of control in a stressful situation.

6. Investigate reports of chest pain, documenting location, duration, intensity (0 to 10 scale), and relieving or aggravating factors. Note nonverbal pain cues, such as facial grimacing, crying, changes in BP and heart rate.

Rationale: Reasons for chest pain are variable and depend on underlying cause. However, chest pain may indicate ischemia due to altered electrical conduction, decreased myocardial perfusion, or increased oxygen need, such as impending or evolving MI.

7. Be prepared to initiate cardiopulmonary resuscitation (CPR), as indicated.

Rationale: Development of life-threatening dysrhythmias requires prompt intervention to prevent ischemic damage or death.