Bradycardia: Nursing Diagnoses & Care Plans

(Risk for) Decreased Cardiac Output

Decreased cardiac output associated with bradycardia can be caused by poor cardiac function resulting in inadequate cardiac output. Bradycardia can be serious if the heart rate is too slow to pump blood to the rest of the body.

Nursing Diagnosis: (Risk for) Decreased Cardiac Output

Related to:

• Bradycardia
• Decreased heart rate 
• Altered afterload 
• Altered contractility 
• Altered heart rhythm 
• Altered preload 
• Altered stroke volume
• Age
• Heart disease
• Congenital heart defect
• Myocarditis
• Side effects of cardiac treatments such as surgery
• Hypothyroidism
• Electrolyte imbalance 
• Obstructive sleep apnea
• Inflammatory conditions like lupus or rheumatic fever

As evidenced by (only with an actual diagnosis):

Note: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at preventing signs and symptoms.

• Hypotension
• Decreased peripheral pulses
• Increased central venous pressure (CVP)
• Increased pulmonary artery pressure (PAP)
• Tachycardia
• Dysrhythmias
• Ejection fraction less than 40%
• Decreased oxygen saturation
• S3 and S4 heart sounds upon auscultation
• Chest pain
• Difficulty breathing (dyspnea)
• Rapid breathing (tachypnea)
• Alteration in the level of consciousness
• Restlessness
• Fatigue
• Activity intolerance
• Cold and clammy skin
• Prolonged capillary refill time

Expected outcomes:

• Patient will demonstrate adequate cardiac output with blood pressure and heart rate within normal limits.
• Patient will demonstrate normal sinus rhythm on EKG.
• Patient will be able to tolerate activities without chest pain, dyspnea, or changes in the level of consciousness.
• Patient will not experience complications of bradycardia and decreased cardiac output, such as heart failure.

Assessment:

1. Determine cardiovascular status.
Heart rate (HR) and stroke volume (SV) are the components of cardiac output. Bradycardia directly reduces cardiac output and may result in shock. Diastolic filling increases with a decreased heart rate, leading to increased stroke volume.

2. Assess symptoms of hypoperfusion and acute coronary syndrome.
Patients experiencing bradycardia are at risk of experiencing sudden and reduced blood flow to the heart, leading to acute coronary syndrome. Manifestations may include chest pain, dyspnea, dizziness, nausea, and fatigue.

3. Obtain a thorough cardiac history.
Cardiac conditions, such as myocardial infarction, heart failure, or congenital defects, can further affect cardiac output and alterations in perfusion.

4. Note any signs and symptoms caused by bradycardia.
The following symptoms may result from bradycardia, which might hinder the brain and other organs from receiving adequate oxygen:

• Angina
• Confusion
• Change in level of consciousness
• Activity intolerance
• Fatigue
• Syncope
• Dyspnea

5. Auscultate the apical pulse.
The fifth intercostal space is the landmark for auscultating the apical pulse. Palpate the radial pulse after auscultating the apical pulse. Do this simultaneously and notice if both pulses are equal.

6. Draw a sample for a blood test.
Laboratory tests should include the following to determine a possible cause of bradycardia:

• Glucose level
• Electrolytes
• Thyroid function
• Troponin levels
• Toxicology drug screen

7. Obtain ECG.
An electrocardiogram (ECG) is the primary test to diagnose bradycardia. Sinus bradycardia occurs when an upright P wave precedes every QRS complex on an ECG in the lead II, known as a sinus P wave, and the ventricular rhythm is fewer than 60 beats per minute.

8. Investigate further bradycardia episodes.
Investigate further using portable ECG equipment (Holter monitor or event recorder) and other tests (such as tilt table test and stress exercise test) since an ECG cannot immediately identify bradycardia unless the slow heartbeat happens during the exam.

Interventions:

1. Perform continuous telemetry monitoring.
For safe assessment, the client with a cardiac history or symptomatic bradycardia should be connected to continuous telemetry monitoring.

2. Monitor the use of sedatives.
Carefully administer opioid analgesia, sedatives, and benzodiazepines, as these medications can further reduce the heart rate and cause respiratory depression.

3. Administer supplemental oxygenation.
Emergency cardiovascular care includes supplemental oxygenation for respiratory distress associated with decreased cardiac output and bradycardia.

4. Instruct on the use of a Holter monitor or an event recorder.
A Holter monitor is a wearable device that records the heart rate and rhythm to detect abnormalities when the patient is experiencing symptoms like chest pain, dizziness, and dyspnea to help pinpoint the cause and assist with treatment planning. An event recorder is similar but isn’t worn at all times.

5. Administer medications as ordered.
For patients with bradycardia who are hemodynamically unstable, push 0.5 mg of atropine intravenously (IV) every 3 to 5 minutes, up to a maximum dose of 3 mg as prescribed.

6. Prepare for pacemaker insertion.
A pacemaker is implanted in the chest to control the heart rate and prevent bradycardia. The nurse assists with preparing the patient prior to surgery, monitoring for complications post-op, and providing discharge instructions.