Nursing Diagnosis: Risk for Decreased Cardiac Output related to structural abnormalities of the heartGoal:
- no decline in cardiac output
- 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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