About
Decreased heart pump effectiveness resulting in impaired tissue and organ oxygenation to meet body demands.
Assess
Hypotension, angina, arrhythmias, pulmonary edema, decreased peripheral pulses
Complications
Multiple Organ dysfunction syndrome, Myocardial ischemia, infarction, cardiac arrest, respiratory arrest, death
Diagnosis
- Decreased cardiac output related to injury to the myocardium.
- Acute pain related to angina.
- Impaired gas exchange related to decreased cardiac output.
- Impaired tissue perfusion related to decreased cardiac output.
Goals
- The client will state a decrease in pain less than 4 on a 0-10 scale.
- The client will maintain a pulse oximetry of greater than 90%.
- The client will maintain a blood pressure within normal ranges.
- The client will remain free from injury.
- The client will have positive peripheral pulses and warmth to extremities.
Interventions
- Assess and monitor frequently ( every 15 minutes- 4hours) vital signs, pulse oximetry, telemetry, ABG's, electrolytes, CBC, CPK-MB, Troponins.
- Administer fluids as ordered.
- Monitor for signs of fluid overload including pulmonary edema or peripheral edema.
- Notify physician of decreases in blood pressure, pulse ox, and labs.
- Implement safety precautions to prevent injury.
- Administer oxygen as ordered.
- Administer nitroglycerin, dobutamine, dopamine, pain meds and other medications as ordered.
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