Goal: Children can maintain adequate cardiac output
NOC:
- Vital signs are normal with age.
- There is no dyspnea, rapid breathing and deep, cyanosis, anxiety / lethargy, tachycardia, murmurs.
- Clients composmetis.
- Akral warm.
- Peripheral pulse strong and equal on both extremities.
- Capillary refill time less than 3 seconds.
- Urine output of 1-2 ml / kg / hour.
Intervention:
- Monitor vital signs, peripheral pulses, capillary refill by comparing measurements at both extremities while standing, sitting and lying down if possible.
- Assess and record the apical pulse for 1 full minute.
- Observation of cyanotic attacks.
- Give a knee-chest position in children.
- Observe for signs of decreased sensory: lethargy, confusion, and disorientation.
- Monitor intake and output adequately.
- Provide adequate rest time for children and accompany children during activity.
- Serve foods that are easily digestible and reduce the consumption of caffeine.
- Collaboration in the examination serial ECGs, chest radiographs, administration of anti dysrhythmias.
- Collaboration of oxygen.
- Collaboration IV fluid administration.