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Nursing Diagnosis: Risk for Decreased Cardiac Output related to structural abnormalities of the heart Goal: no decline in cardiac output Expected outcomes are: vital signs within normal limits, free of symptoms of heart failure, reported a decrease in episodes of dyspnoea, participate in activities that reduce the heart's workload, adequate urine output: 0.5 to 2 ml / kg body weight.
Nursing Interventions - Risk for Decreased Cardiac Output related to Tetralogy of Fallot: 1. Assess the pulse rate, respiration, blood pressure regularly every 4 hours. R :/ Monitoring the change of heart circulation as early as possible. 2. Record the heart sounds. R :/ Know of any changes in heart rhythm. 3. Assess changes in skin color of the cyanosis and pallor. R :/ Pale showed a decrease in peripheral perfusion to inadequate cardiac output. Cyanosis occurs as a result of obstruction of blood flow to the ventricles. 4. Limit your activities adequately. R :/ adequate rest is needed to improve the efficiency of cardiac contraction and oxygen consumption and reduce redundant work. 5. Monitor intake and output every 24 hours. R :/ kidneys respond to decrease cardiac output by withholding the production of fluid and sodium. 6. Provide a quiet environment of psychological conditions. R :/ emotional stress produces vasoconstriction which increases blood pressure and increased heart work.
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Risk for Decreased Cardiac Output Tetralogy of Fallot