Decreased Cardiac Output, Nursing Assessment and Rationales for Decreased Cardiac Output, Nursing Interventions and Rationales for Decreased Cardiac Output, and 5 Nursing Care Plans for Decreased Cardiac Output

Decreased Cardiac Output, Nursing Assessment and Rationales for Decreased Cardiac Output, Nursing Interventions and Rationales for Decreased Cardiac Output, and 5 Nursing Care Plans for Decreased Cardiac Output

This guide is about Decreased Cardiac Output, Nursing Assessment and Rationales for Decreased Cardiac Output, Nursing Interventions and Rationales for Decreased Cardiac Output, and 5 Nursing Care Plans for Decreased Cardiac Output. It can be used to create educational nursing care plans for Decreased Cardiac Output.

Decreased Cardiac Output

Decreased Cardiac Output

What is Decreased Cardiac Output?

Cardiac output is the amount of blood pumped by the heart per minute. It is the product of the heart rate, which is the number of beats per minute, and the stroke volume, which is the amount pumped per beat. CO = HR X SV. The cardiac output is usually expressed in liters/minute. he normal range for cardiac output is between 4 to 8 liters per minute. Decreased Cardiac Output is a nursing diagnosis that refers to the cardiac output level below 4 liters per minute. Cardiovascular diseases such as myocardial infarction, heart failure, dysrhythmias, and other problems in fluid volume or effects of some drugs can cause a decrease in cardiac output.

What Causes Decreased Cardiac Output?

Conditions like myocardial infarction, hypertension, valvular heart disease, congenital heart disease, cardiomyopathy, heart failure, pulmonary disease, arrhythmias, drug effects, fluid overload, decreased fluid volume, and electrolyte imbalance is common causes of decreased cardiac output. Additionally, here are some factors that may be related to decreased cardiac output:

  • Alteration in heart rate, rhythm, and conduction
  • Cardiac muscle disease
  • Decreased oxygenation
  • Impaired contractility
  • Increased afterload
  • Increased or decreased ventricular filling (preload)

What are the Signs and Symptoms of Decreased Cardiac Output?

A decrease in cardiac output is characterized by the following manifestations:

  • Abnormal heart sounds (S3, S4)
  • Angina
  • Anxiety, restlessness
  • Change in level of consciousness
  • Crackles, dyspnea, orthopnea, tachypnea
  • Decreased activity tolerance
  • Decreased cardiac output
  • Decreased peripheral pulses; cold, clammy skin/poor capillary refill
  • Decreased venous and arterial oxygen saturation
  • Dysrhythmias
  • Ejection fraction less than 40%
  • Fatigue
  • Hypotension
  • Increased central venous pressure (CVP)
  • Increased pulmonary artery pressure (PAP)
  • Tachycardia
  • Weight gain, edema, decreased urine output

What are the Goals and Outcomes of Decreased Cardiac Output?

The following are the common goals and expected outcomes for the nursing diagnosis of decreased cardiac output:

  • Patient 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.
  • Patient exhibits warm, dry skin, eupnea with absence of pulmonary crackles.
  • Patient remains free of side effects from the medications used to achieve adequate cardiac output.
  • Patient explains actions and precautions to take for cardiac disease.

Nursing Assessment and Rationales for Decreased Cardiac Output

What assessment findings would indicate decreased cardiac output?

Assessment is required to distinguish possible problems that may have led to decreased cardiac output and name any episode during nursing care.

1. Assess heart rate and blood pressure.

Nursing Assessment and Rationales for Decreased Cardiac Output

Compensatory tachycardia is a common response for patients with significantly low blood pressure to reduce cardiac output. Initially, this compensatory response has a favorable effect on cardiac output but can be harmful when it becomes persistent.

2. Check for peripheral pulses. Perform capillary refill test (CRT).
Weak pulses are present in reduced stroke volume and cardiac output. Capillary refill is sometimes slow or absent. Current studies indicate that capillary refill test measurement is affected by multiple external factors (Pickard et al., 2011). CRT is an easy and quick test to perform; unfortunately, its results cannot be interpreted with any degree of confidence in the adult population (Lewin & Maconochie, 2008). Clinical decisions should not be based on CRT measurement alone.

3. Auscultate heart sounds for gallops (S3, S4); auscultate breath sounds.
The new onset of a gallop rhythm, tachycardia, and fine crackles in lung bases can indicate the onset of heart failure. If the patient develops pulmonary edema, there will be coarse crackles on inspiration and severe dyspnea. Sindicates reduced left ventricular ejection and is a class sign of left ventricular failure. Soccurs with reduced compliance of the left ventricle, which impairs diastolic filling.

4. Note skin color, temperature, and moisture.
Cold, clammy, and pale skin is secondary to a compensatory increase in sympathetic nervous system stimulation and low cardiac output and oxygen desaturation (Leier, 2007; Bolger, 2003).

5. Check for any alterations in level of consciousness.
Decreased cerebral perfusion and hypoxia are reflected in irritability, restlessness, and difficulty concentrating. Older patients are particularly susceptible to reduced cerebral perfusion. Alterations in cardiac output, either acutely or chronically, can lead to changes in cerebral blood flow (Meng et al., 2015).

6. Note respiratory rate, rhythm, and breath sounds. Identify any presence of paroxysmal nocturnal dyspnea (PND), orthopnea.
Shallow, rapid respirations are characteristics of decreased cardiac output. Crackles indicate fluid buildup secondary to impaired left ventricular emptying. Orthopnea is defined as aggravated shortness of breath when lying down; it is common among patients with cardiovascular disorders (Martins et al., 2010). Paroxysmal nocturnal dyspnea (PND) is a sensation of shortness of breath that awakens the patient, often after 1 or 2 hours of sleep, and is usually relieved in the upright position (Mukerji, 2011). PND is closely related to decreased cardiac output. While sleeping at night, peripheral edema is reabsorbed, causing systemic and pulmonary hypervolemia, with consequent aggravation of pulmonary congestion ultimately leading to PND.

7. Assess oxygen saturation with pulse oximetry both at rest and during and after ambulation.
An alteration in oxygen saturation is one of the earliest signs of reduced cardiac output. Hypoxemia is common, especially with activity. Administer supplemental oxygen as needed.

8. Note chest pain. Identify location, radiation, severity, quality, duration, associated manifestations such as nausea, and precipitating and relieving factors.
Chest pain or chest discomfort generally suggests myocardial ischemia or inadequate blood supply to the heart, which can compromise cardiac output (Yancy et al., 2017).

9. Inspect fluid balance and weight gain. Weigh the patient regularly before breakfast. Check for pedal and sacral edema.
Compromised regulatory mechanisms may result in fluid and sodium retention and increase fluid volume. Bodyweight is a more sensitive indicator of fluid or sodium retention than intake and output. Edema is a determining characteristic of heart failure. Hepatojugular reflux and peripheral edema were the physical signs that demonstrated the best discriminative ability to differentiate levels of right atrial pressure (Goldraich et al., 2004).

10. Monitor urine output. If the patient is acutely ill, measure hourly urine output and note a decrease in output.
Reduced cardiac output results in reduced perfusion of the kidneys, with a resulting decrease in urine output.

11. Assess beta-type natriuretic peptide (BNP).
BNP is a neurohormone secreted from the cardiac ventricles and is elevated due to increasing filling pressure and volume in the left ventricle. BNP can differentiate heart failure from other causes of dyspnea in patients (Harrison et al., 2002).

12. If hemodynamic monitoring is in place, assess CVP, pulmonary artery diastolic pressure (PADP), pulmonary capillary wedge pressure (PCWP), as well as cardiac output, and cardiac index.
CVP provides information on filling pressures of the right side of the heart; PADP and PCWP reflect left-sided fluid volumes. The cardiac output provides an objective number to guide therapy.

13. Closely monitor for symptoms of heart failure and decreased cardiac output.
These symptoms include diminished quality of peripheral pulses, cold and clammy skin and extremities, increased respiratory rate, presence of paroxysmal nocturnal dyspnea or orthopnea, increased heart rate, neck vein distention, decreased level of consciousness, and presence of edema. As these symptoms of heart failure progress, cardiac output declines (Yancy et al., 2017).

14. Assess for reports of fatigue and reduced activity tolerance.
Fatigue and exertional dyspnea are common problems with low cardiac output states. Close monitoring of the patient’s response serves as a guide for optimal progression of activity. Fatigue is the chief complaint reported by patients with heart failure; it has the largest effect on the daily activities and quality of life of these patients (Martins et al., 2010).

15. Ascertain contributing factors so an appropriate care plan can be initiated.
Recognizing these factors can help guide the treatment regimen.

16. Monitor electrocardiogram (ECG) for rate, rhythm, and ectopy.
Cardiac dysrhythmias may occur from low perfusion, acidosis, or hypoxia. Tachycardia, bradycardia, and ectopic beats can further compromise cardiac output. Older patients are susceptible to the loss of atrial kick in atrial fibrillation.

17. Review results of EKG and chest X-ray.
These tests can help indicate the underlying cause of decreased cardiac output. EKG can reveal previous MI or left ventricular hypertrophy, indicating aortic stenosis or chronic systemic hypertension. A chest x-ray may provide information on pulmonary edema, pleural effusions, or enlarged cardiac silhouette found in dilated cardiomyopathy or large pericardial effusion.

18. Examine laboratory data, especially arterial blood gases and electrolytes, including potassium.
The patient may be receiving cardiac glycosides, and the potential for toxicity is greater with hypokalemia; hypokalemia is common in heart patients because of diuretic use.

19. Monitor laboratory tests such as complete blood count, sodium level, and serum creatinine.
Routine blood work can provide insight into the etiology of heart failure and the extent of decompensation. A low serum sodium level often is observed with advanced heart failure and can be a poor prognostic sign. Serum creatinine levels will elevate in patients with severe heart failure because of decreased perfusion to the kidneys. Creatinine may also elevate because of ACE inhibitors.

Nursing Interventions and Rationales for Decreased Cardiac Output


What can you teach a patient with low cardiac output?


The following are the therapeutic nursing interventions for a decreased cardiac output which you can use for writing your nursing care plans (NCP):

1. For patients with increased preload, limit fluids and sodium as ordered.
Fluid restriction decreases the extracellular fluid volume and reduces demands on the heart.

2. Closely monitor fluid intake, including IV lines. Maintain fluid restriction if ordered.
In patients with decreased cardiac output, poorly functioning ventricles may not tolerate increased fluid volumes.

3. If chest pain is present, have the patient lie down, monitor cardiac rhythm, give oxygen, run a strip, medicate for pain, and notify the physician.
These actions can increase oxygen delivery to the coronary arteries and improve patient prognosis. Symptoms can also be manifestations of myocardial ischemia and should be reported immediately.

4. Place on a cardiac monitor; monitor for dysrhythmias, especially atrial fibrillation.

Cardiac Monitoring

Atrial fibrillation is common in heart failure and can cause a thromboembolic event.

5. Observe patient for understanding and compliance with medical regimen, including medications, activity level, and diet.
This promotes the cooperation of the patient in their own medical situation.

6. Maintain adequate ventilation and perfusion as in the following:

  • 6.1. Position patient in semi-Fowler’s to high-Fowler’s
    Upright position is recommended to reduce preload and ventricular filling when fluid overload is the cause.
  • 6.2.Place the patient in a supine position
    For hypovolemia, supine positioning increases venous return and promotes diuresis.

7. Administer oxygen therapy as prescribed.
The failing heart may not be able to respond to increased oxygen demands. Oxygen saturation needs to be greater than 90%.

8. Administer medications as prescribed, noting side effects and toxicity.
Depending on etiological factors, common medications include digitalis therapy, diuretics, vasodilator therapy, antidysrhythmics, angiotensin-converting enzyme inhibitors, and inotropic agents.

9. During acute events, ensure the patient remains on bed rest or maintains an activity level that does not compromise cardiac output.
In severe heart failure, restriction of activity often facilitates temporary recompensation.

10. Monitor blood pressure, pulse, and condition before administering cardiac medications such as angiotensin-converting enzyme (ACE) inhibitors, digoxin, and beta-blockers such as carvedilol. Notify the physician if heart rate or blood pressure is low before holding medications.
The nurse must assess how well the patient tolerates current medications before administering cardiac medications; do not hold medications without physician input. The physician may decide to have medications administered even though the blood pressure or pulse rate has lowered.

11. Monitor bowel function. Provide stool softeners as ordered. Tell the patient to avoid straining when defecating.
Decreased activity can cause constipation. When defecating, that results in the Valsalva maneuver, straining can lead to dysrhythmia, decreased cardiac function, and sometimes death.

12. Identify emergency plan, including use of CPR.
Persistent decreased cardiac output can be life-threatening.

13. Advise patient to use a commode or urinal for toileting and avoid using a bedpan.
Getting out of bed to use a commode or urinal does not stress the heart more than staying in bed to the toilet. In addition, getting the patient out of bed minimizes complications of immobility and is often preferred by the patient.

14. Apply music therapy to decrease anxiety and improve cardiac function.
Music has been shown to reduce heart rate, blood pressure, anxiety, and cardiac complications (Hanser, 2014; Chuang et al., 2010).

15. Associate patient to heart failure or cardiac rehabilitation program for education, evaluation, and guided support to increase activity and rebuild a life.
A thoroughly monitored exercise program can improve both functional capacities and left ventricular function. Cardiac rehabilitation can improve quality of life and functional capacity and decrease mortality.

16. Explain the importance of smoking cessation and avoidance of alcohol intake.
Educating the patient on the effects of smoking can help them understand the health risks involve in smoking. Smoking is associated with an increased risk of heart failure, but the risk decreases with increasing duration since smoking cessation (Aune et al., 2019). Any form of heavy drinking of alcohol should be discouraged (Rehm & Roerecke, 2017).

17. Educate the patient and significant other about the disease process, complications of the disease process, information on medications, need for weighing daily, and when appropriate to call a primary care provider.
Early recognition of symptoms facilitates early problem solving and prompt treatment.

18. Aid family to adapt daily living patterns to establish life changes that will maintain improved cardiac functioning in the patient.
Transition to the home setting can cause risk factors such as inappropriate diet to reemerge.

19. Educate patients on the need for and how to incorporate lifestyle changes.
Psychoeducational programs including information on stress management and health education have been shown to reduce long-term mortality and recurrence of myocardial infarction in heart patients.

5 Nursing Care Plans for Decreased Cardiac Output

What are the Available Nursing Care Plans for Decreased Cardiac Output?

Decreased Cardiac Output Nursing Care Plan 1

Congenital Heart Disease

Nursing Diagnosis: Decreased cardiac output related to structural heart defect secondary to atrial septal defect as evidenced by feeding difficulties

Desired Outcome: The patient will maintain or demonstrate improvement in cardiac output while waiting for treatment as evidenced by improved feeding ability.

Nursing Interventions for Decreased Cardiac Output Rationale
Monitor and record vital signs. Vital signs measure the status of circulation and perfusion. Constant or sudden changes in the patient’s vital signs can signify unresolved or worsening condition. After treatment, the patient’s vital signs will also be a non-invasive way to evaluate the success of the procedure.
Assess the patient’s skin color, texture, temperature, and moisture. tissue perfusion can be assessed through the patient’s skin. Decreased cardiac output can be manifested by cold, clammy, and pale skin. Also, if the patient has difficulty feeding, assessment of the skin’s moisture can help signify dehydration and can direct treatment to provide supplemental nutrition.
Encourage a relaxed and restful environment. A relaxed and restful environment can help reduce the body’s metabolic requirement.
Provide supplemental oxygen as necessary. A reduced cardiac output can cause a reduced delivery of oxygen in the systemic circulation. Oxygen supplementation may be required in some cases.
Position the patient in semi-fowler’s position as tolerated. An upright position aids maximum lung expansion.
Administer supplemental nutrition as ordered. Due to the reduced oxygen delivery in the system, the patient may experience easy fatiguability which can affect his/her ability to feed. The patient’s nutrition may be compromised and supplementation may be required.

Decreased Cardiac Output Nursing Care Plan 2

Heart Valve Disease

Nursing Diagnosis: Decreased cardiac output related to altered heart rate secondary to valvular heart disease as evidenced by a persistent heart rate of >120 bpm

Desired Outcome: The patient will demonstrate understanding of interventions to reduce cardiac workload.

Nursing Interventions for Decreased Cardiac Output Rationale
Assess and record the patient’s vital signs and oxygen saturation. The patient’s vital signs are important markers to monitor the status of tissue perfusion which is directly affected by the cardiac output. The oxygen saturation can measure peripheral perfusion.
Assess the characteristics and presence of the patient’s peripheral pulses. A decreased cardiac output can be manifested by weak peripheral pulses.
Monitor the patient’s urine output and commence the patient on a fluid balance chart. The body compensates from decreased cardiac output by reabsorbing fluid from the renal tubules back into systemic circulation to increase blood volume.
Discuss the signs and symptoms of decreased cardiac output with the patient using easy-to-understand words. The patient will need to understand his/her condition fully to promote compliance to the prescribed treatments.
Discuss ways to reduce oxygen requirements with the patient: Bed rest Promote normal, regular breathing, Reduce unnecessary activities, Request for assistance with intensive activities, Semi to high-fowler’s position, Use of bedside commode, and Elevation of legs There are ways to reduce the body’s metabolic requirements. These will help the body to meet oxygen demand and minimize the serious effects of decreased cardiac output.
Allow time for questions from the patient. The patient may have questions regarding his/her condition. Being available to answer questions can relieve his/her anxieties which will help promote relaxation.

Decreased Cardiac Output Nursing Care Plan 3

Aortic Aneurysm

Nursing Diagnosis: Decreased cardiac output related to progressive dissection of the aorta secondary to aortic aneurysm

Desired Outcome: The patient will maintain adequate cardiac output as evidenced by stable vital signs and normal level of consciousness.

Nursing Interventions for Decreased Cardiac Output Rationale
Monitor and record the patient’s vital signs, oxygen saturation, urine output, and neurologic status. The vital signs, oxygen saturation, and neurologic status measure the patient’s hemodynamic status. Fluctuating and severely high or low readings are critical markers for the urgency for interventions to be carried out.
Prepare the patient for surgical interventions. The dissection of the aorta is a serious medical emergency that needs prompt treatment.
Collect blood samples for routine blood tests and crossmatching. The patient may need blood transfusion to maintain adequate blood volume.
Administer medications and intravenous fluids as prescribed. Patients with aortic dissection may need medications and additional fluid to support adequate blood volume.
Provide supplemental oxygenation. Oxygen supplementation may be required to help the body meet the metabolic demand.

Decreased Cardiac Output Nursing Care Plan 4

Acute Coronary Syndrome

Nursing Diagnosis: Decreased cardiac output secondary to increased vascular resistance as evidenced by high blood pressure level of 170/89, fatigue and inability to do ADLs as normal

Desired outcome: The patient will be able to regain adequate cardiac output.

Nursing Interventions for Decreased Cardiac Output Rationale
Assess the patient’s vital signs and characteristics of heart beat at least every 4 hours. Assess heart sounds via auscultation. Observe for signs of decreasing peripheral tissue perfusion such as slow capillary refill, facial pallor, cyanosis, and cool, clammy skin. To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. The presence of signs of decreasing peripheral tissue perfusion indicate deterioration of the patient’s status which require immediate referral to the physician.
Administer prescribed medications for acute coronary syndrome. Aspirin – to reduce the ability of the blood to clot, so that the blood flows easier through the narrowed arteries. Nitrates – to relax the blood vessels. Anti-cholesterol drugs (e.g. statins) – to reduce the deposits on the arterial walls  Beta blockers – to decrease the cardiac demand for oxygen by means of lowering the heart rate and blood pressure levels Calcium channel blockers – used in combination with beta blockers Ranolazine – to treat anginaAdminister supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician. To increase the oxygen level and achieve an SpO2 value within the target range.
Educate patient on stress management, deep breathing exercises, and relaxation techniques. Stress causes a persistent increase in cortisol levels, which has been linked to people with cardiac issues. Chronic stress may also cause an increase in adrenaline levels, which tend to increase the heart rate, respiratory rate, and blood sugar levels. Reducing stress is also an important aspect of dealing with fatigue.

Decreased Cardiac Output Nursing Care Plan 5

Beta Blocker Toxicity / Overdose

Nursing Diagnosis: Decreased cardiac output secondary to beta blocker toxicity as evidenced by respiratory rate of 10 cycles per minute (bradypnea), blood pressure level of 80/50 (hypotension), difficulty of breathing or shortness of breath, arrhythmia, excessive sweating, light-headedness and dizziness

Desired outcome: The patient will be able to regain adequate cardiac output.

Nursing Interventions for Decreased Cardiac Output Rationale
Attach the patient to a cardiac monitor and check vital signs at least every 15 to 30 minutes until stable. To monitor the patient’s respiratory rate, heart rate, and blood pressure levels which are deranged due to beta blocker toxicity.
Perform first aid for beta blocker toxicity or overdose, which includes: Gastric lavage, Administration of activated charcoal, and Administration of adrenaline To reverse the side effects of beta blocker toxicity or overdose, the following should be done: Gastric lavage to eliminate the drug from the stomach, Administration of activated charcoal to avoid absorption, Administration of adrenaline, which is an antidote, to counter the effects of the drug
Ask the patient questions on self-administration of beta blockers. To verify whether the symptoms are due to overdose of beta blockers and to determine when the symptoms have begun. Exploring the cause may also inform the nurse why the overdose happened, as some patients may have done this for self-harm and therefore requires psychological and social support.
Do not abruptly stop beta blockers. Administer them in tapered doses as prescribed by the physician. Beta blockers should not be discontinued abruptly as doing so may increase the likelihood of a heart attack and other cardiac problems.
Administer beta blockers ideally with meals and/or at bedtime. To ensure optimal absorption and therapeutic action by beta blockers, as well as reduce possible side effects.
Administer beta blockers about 1 hour before or 2 hours after administering other oral medications, as prescribed. Ideal spacing of beta blockers and other oral medications will ensure adequate absorption of the drugs administered.
Discourage intake of fish oil, grape juice, and orange juice with beta blockers. Fish oil can enhance hypotensive effect of beta blockers. Grape juice and orange juice can affect the potency of the drugs.
Encourage tobacco smoking sensation and reduction of alcohol consumption. Tobacco smoking and alcohol can reduce the benefits of beta blockers. Alcohol consumption must be avoided during the course of treatment, because alcohol can lower the blood pressure, increase dizziness, and pose the risk for sudden hypotension.
Encourage the patient to change position slowly. To prevent orthostatic hypotension.
Advise the patient not to break or crush the medications, unless it is safe to do so. Sustained release beta blocker tablets should not be broken or crushed as doing so may affect the potency of the drugs.

References and Sources

Recommended journals, books, and other interesting materials to help you learn more about decreased cardiac output nursing diagnosis:

  1. Aune, D., Schlesinger, S., Norat, T., & Riboli, E. (2019). Tobacco smoking and the risk of heart failure: A systematic review and meta-analysis of prospective studies. European journal of preventive cardiology, 26(3), 279-288.
  2. Bolger, A. P., Coats, A. J., & Gatzoulis, M. A. (2003). Congenital heart disease: the original heart failure syndrome. European Heart Journal, 24(10), 970-976.
  3. Chuang, C. Y., Han, W. R., Li, P. C., & Young, S. T. (2010). Effects of music therapy on subjective sensations and heart rate variability in treated cancer survivors: a pilot study. Complementary therapies in medicine, 18(5), 224-226.
  4. Hanser, S. B. (2014). Music therapy in cardiac health care: current issues in research. Cardiology in review, 22(1), 37-42.
  5. Harrison, A., Morrison, L. K., Krishnaswamy, P., Kazanegra, R., Clopton, P., Dao, Q., … & Maisel, A. S. (2002). B-type natriuretic peptide predicts future cardiac events in patients presenting to the emergency department with dyspnea. Annals of emergency medicine, 39(2), 131-138.
  6. Leier, C. V., & Chatterjee, K. (2007). The physical examination in heart failure—Part I. Congestive Heart Failure, 13(1), 41-47.
  7. Lewin, J., & Maconochie, I. (2008). Capillary refill time in adults. Emergency Medicine Journal, 25(6), 325-326.
  8. Lívia Goldraich, M. S., Grazziotin, T. C., Rohde, L. E., Beck-da-Silva, L., & Goldraich, L. (2004). Reliability and prognostic value of traditional signs and symptoms in outpatients with congestive heart failure. Can J Cardiol, 20(7), 697.
  9. Martins, Q. C. S., Aliti, G., & Rabelo, E. R. (2010). Decreased cardiac output: clinical validation in patients with decompensated heart failure. International Journal of Nursing Terminologies and Classifications, 21(4), 156-165.
  10. Meng, L., Hou, W., Chui, J., Han, R., & Gelb, A. W. (2015). Cardiac output and cerebral blood flow: the integrated regulation of brain perfusion in adult humans. Anesthesiology, 123(5), 1198-1208.
  11. Mukerji, V. (2011). Dyspnea, orthopnea, and paroxysmal nocturnal dyspnea.
  12. Pickard, A., Karlen, W., & Ansermino, J. M. (2011). Capillary refill time: is it still a useful clinical sign?. Anesthesia & Analgesia, 113(1), 120-123.
  13. Rehm, J., & Roerecke, M. (2017). Cardiovascular effects of alcohol consumption. Trends in cardiovascular medicine, 27(8), 534-538.
  14. Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey Jr, D. E., Colvin, M. M., … & Westlake, C. (2017). 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Journal of the American College of Cardiology70(6), 776-803.

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