Question

Mr. Ocampo has been diagnosed with acute heart failure and myocardial infarction. The nurse adds a nursing diagnosis to the client's plan of care of decreased cardiac output when which finding is noted on assessment?

1) One-sided weakness
2) Crackles auscultated in bilateral lung bases
3) Capillary refill <2 seconds
4) Increased pedal pulses

Answer 1

The addition of the nursing diagnosis of decreased cardiac output for Mr. Ocampo is supported by the finding of crackles auscultated in bilateral lung bases, which indicates fluid in the lungs due to poor heart pump function.

Step-by-step explanation:

A nursing diagnosis of decreased cardiac output would be added to Mr. Ocampo's plan of care when crackles auscultated in bilateral lung bases are noted on assessment. This is because crackles are indicative of fluid accumulation in the lungs, which can occur when the heart's pumping efficiency is compromised, as seen in conditions like acute heart failure and myocardial infarction. This manifestation suggests that the heart is not able to pump blood effectively through the body, leading to a backup of fluid in the lungs, known as pulmonary edema. Other findings like one-sided weakness may indicate a neurological issue, a capillary refill <2 seconds is a normal finding, and increased pedal pulses may actually suggest good peripheral circulation rather than decreased cardiac output.