Ndx#1: Decrease cardiac output related to alteration in heart rate, rhythm, and conduction as

evidenced by heart rate of 42 bpm

Goal: Demonstrates adequate cardiac output as evidenced by blood pressure and pulse rate and
rhythm within normal parameters for patient; strong peripheral pulses; and an ability to tolerate
activity without symptoms of dyspnea, syncope, or chest pain.

Outcome Indicators:

1. Remains free of side effects from the medications used to achieve adequate cardiac
output.
2. Exhibits warm, dry skin, eupnea with absence of pulmonary crackles

INTERVENTIONS EVALUATION
1. Note skin color, temperature, and
moisture (Rationale: Cold, clammy,
and pale skin is secondary to
compensatory increase in sympathetic
nervous system stimulation and low
cardiac output and oxygen
desaturation).

2. Check for any alterations in level of

consciousness (Rationale: Decreased
cerebral perfusion and hypoxia are
reflected in irritability, restlessness,
and difficulty concentrating. Aged
patients are particularly susceptible to
reduced perfusion).

3. Assess heart rate and blood pressure

(Rationale: Most patients have
compensatory tachycardia and
significantly low blood pressure in
response to reduced cardiac output).

4. Check for peripheral pulses, including

capillary refill (Rationale: Weak
pulses are present in reduced stroke
volume and cardiac output. Capillary
refill is sometimes slow or absent).
 5. Administer medications as prescribed,
noting side effects and toxicity
(Rationale: Depending on etiological
factors, common medications include
digitalis therapy, diuretics, vasodilator
therapy, antidysrhythmics,
angiotensin-converting enzyme
inhibitors, and inotropic agents).

Ndx#2: Impaired tissue perfusion related to decrease cardiac output as evidenced by chest pain

Goal: Maintains maximum tissue perfusion to vital organs, as evidenced by warm and dry skin,
present and strong peripheral pulses, vitals within patient’s normal range, balanced I&O, absence
edema, normal ABGs, alert LOC, and absence of chest pain.

Outcome Indicators:

1. Verbalizes or demonstrates normal sensations and movement as appropriate.

2. Shows no further worsening/repetition of deficits.
3. Identifies necessary lifestyle changes.

INTERVENTIONS EVALUATION
1. Assess for signs of decreased tissue
perfusion (Rationale: Particular
clusters of signs and symptoms occur
with differing causes. Evaluation
provides a baseline for future
comparison).

2. Check respirations and absence of

work of breathing (Rationale: Cardiac
pump malfunction and/or ischemic
pain may result in respiratory distress.
Nevertheless, abrupt or continuous
dyspnea may signify thromboembolic
pulmonary complications).

3. Maintain optimal cardiac output

(Rationale: This ensures adequate
perfusion of vital organs).
 4. Maintain oxygen therapy as ordered
(Rationale: To prevent further
complications).

5. Provide knowledge on normal tissue

perfusion and possible causes of
impairment (Knowledge of causative
factors provides a rationale for
treatments).

Ndx#3: Acute pain related to tissue ischemia as evidenced by radiating chest pain with a pain
scale of 9/10

Goal: Alleviate Pain

Outcome Indicators:

1. Uses pharmacological and nonpharmacological pain-relief strategies.

2. Displays improvement in mood and coping

INTERVENTIONS EVALUATION
1. Assess pain characteristics (Rationale:
Appraisal of agony encounter is the
initial phase in arranging torment
administration procedures. The most
solid wellspring of data about the
torment is the patient. Enlightening
scales, for example, a visual simple
can be used to recognize the level of
agony).

2. Survey for signs and indications

identifying with torment (Regard for
related signs may help the medical
attendant in assessing torment. An
expansion in BP, HR, and temperature
might be available in a patient with
intense agony. The patient's skin
might be pale and cool to contact.
Anxiety and powerlessness to think
are likewise a few appearances).
 3. Foresee the need for pain relief
(Rationale: Preventing the pain is one
thing that a patient experiencing it can
consider. Early intervention may
decrease the total amount of analgesic
required).

4. Dispose of extra stressors or

wellsprings of distress at whatever
point conceivable (Rationale: Patients
may encounter a distortion in torment
or a diminished capacity to endure
difficult upgrades if ecological,
intrapersonal, or intrapsychic factors
are further focusing on them).

5. Determine the appropriate pain relief

method (Rationale: Patients with acute
pain should be given a nonopioid
analgesic around-the-clock unless
contraindicated).

Ndx#4: Activity intolerance related to imbalanced between myocardial oxygen supply and needs
as evidenced by chest pain with a pain scale of 9/10

Goal: Exhibit tolerance during physical activity as evidenced by a normal fluctuation of vital
signs during physical activity.

INTERVENTIONS EVALUATION
1. Assess the physical activity level and
mobility of the patient (Rationale:
Provides baseline information for
formulating nursing goals during goal
setting).

2. Assess the patient’s nutritional status

(Rationale: Adequate energy reserves
are needed during activity).

3. Provide emotional support and

positive attitude regarding abilities
(Rationale: Patient may be fearful of
 overexertion and potential damage to
the heart. Appropriate supervision
during early efforts can enhance
confidence).

4. Teach the patient and/or SO to

recognize signs of physical
overactivity or overexertion
(Rationale: Knowledge promotes
awareness to prevent the complication
of overexertion).

5. Encourage conscious-controlled
breathing techniques (e.g., pursed-lip
breathing and diaphragmatic
breathing) during increased activity
and times of emotional or physical
stress (Rationale: To promote
relaxation).

Ndx#5: Risk for fall related to fatigue

Goal: Avoid fall

Outcome Indicators: The patient will be able to:

1. Not sustain fall.

2. Relate the intent to use safety measures to prevent falls.

INTERVENTIONS EVALUATION
1. Assess for circumstances associated to
increase the level of fall risk upon
admission, following any alteration in
the patient’s physical condition or
cognitive status, whenever a fall
happens, systematically during a
hospital stay, or at defined times in
long-term care settings (Rationale: A
fall is more likely to be experienced
by an individual if the surrounding is
not familiar such as the placement of
furniture and equipment in a certain
area).
2. Provide signs or secure a wristband
identification to remind healthcare
providers to implement fall precaution
behaviors (Rationale: Signs are vital
for patients at risk for falls. Healthcare
providers need to acknowledge who
has the condition for they are
responsible for implementing actions
to promote patient safety and prevent
falls).

3. Move items used by the patient within

easy reach, such as call light, urinal,
water, and telephone (Rationale: Items
that are too far from the patient may
cause hazard and can contribute to
falls).

4. Respond to call light as soon as

possible (Rationale: This is to prevent
the patient from going out of bed
without any assistance).

5. Avoid the use of restraints to reduce

falls (Rationale: Studies demonstrate
that regular use of restraints does not
reduce the incidence of falls).