Nursing diagnosis: risk for decreased Cardiac Output
Risk factors may include
Fluid overload—kidney dysfunction or failure, overzealous fluid replacement
Fluid shifts, fluid deficit (excessive losses)
Electrolyte imbalance (potassium, calcium), severe acidosis
Uremic effects on cardiac muscle, oxygenation
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Maintain cardiac output as evidenced by BP and HR and rhythm within client’s normal limits and peripheral pulses strong and equal, with adequate capillary refill time.
Nursing intervention with rationale:
1. Monitor BP and heart rate.
Rationale: Fluid volume excess, combined with hypertension, which often occurs in renal failure, and effects of uremia increase cardiac workload and can lead to cardiac failure. In ARF, cardiac failure is usually reversible.
2. Observe ECG or telemetry for changes in rhythm.
Rationale: Changes in electromechanical function may become evident in response to accumulation of toxins and electrolyte imbalance. For example, hyperkalemia is associated with a peaked T wave, wide QRS complex, prolonged PR interval, and flattened or absent P wave. Hypokalemia is associated with flattened T wave, peaked P wave, and appearance of U waves. Prolonged QT interval may reflect calcium deficit.
3. Auscultate heart sounds.
Rationale: Development of S3/S4 is associated with congestive HF. Pericardial friction rub may be only manifestation of uremic pericarditis, requiring prompt intervention and, possibly, acute dialysis.
4. Assess color of skin, mucous membranes, and nailbeds. Note capillary refill time.
Rationale: Pallor may reflect vasoconstriction or anemia—common in ARF, whether associated with actual blood loss or abnormalities in life of RBCs. Cyanosis is a late sign and is related to pulmonary congestion or cardiac failure. A long capillary refill time is associated with hypovolemic states.
5. Note occurrence of slow pulse, hypotension, flushing, nausea or vomiting, and depressed LOC—central nervous system (CNS) depression.
Rationale: Magnesium is typically decreased with ARF. If client is also using drugs (e.g., antacids) containing magnesium, the result can be significant hypomagnesemia, potentiating neuromuscular dysfunction and risk of respiratory or cardiac arrest.
6. Investigate reports of muscle cramps, numbness or tingling of fingers, with muscle twitching and hyperreflexia.
Rationale: These are symptoms of hypocalcemia. Calcium levels are typically somewhat decreased with ARF. If phosphorus levels are also high, hypocalcemia can become severe, which can also affect cardiac contractility and function.
7. Maintain bedrest or encourage adequate rest and provide assistance with care and desired activities.
Rationale: Reduces oxygen consumption and cardiac workload.
8. Administer and restrict fluids as indicated. (Refer to NDs: excess Fluid Volume.)
Rationale: Cardiac output depends on circulating volume—affected by both fluid excess and deficit—and myocardial muscle function.
9. Administer medications, as indicated, such as: Inotropic agents
Rationale: May be used to improve cardiac output by increasing myocardial contractility and stroke volume.
10. Prepare for and assist with dialysis, as necessary.
Rationale: May be indicated for persistent dysrhythmias and progressive HF unresponsive to other therapies.