Nursing Care Plan for Cardiogenic Shock

Pathophysiology

Cardiogenic shock is a state in which the organs are not receiving adequate oxygenated blood because of severe pump (heart) failure. It is an acute, sudden, extreme version of heart failure and is a medical emergency.

Etiology

A myocardial infarction can cause cardiogenic shock because the heart muscle cannot pump effectively. Things that obstruct the flow of blood to the body can also cause cardiogenic shock – that includes cardiac tamponade (fluid build up around the heart that compresses it and prevents pumping) and pulmonary embolism (blood clot in the pulmonary arteries that prevent forward flow and prevent oxygenation of the blood).

Desired Outome

The goal is to reverse the cause and restore sufficient cardiac output to the tissues. The hope would be to prevent any permanent damage from tissue ischemia and to prevent recurrence of cardiogenic shock.

Cardiogenic Shock Nursing Care Plan

Subjective Data:

  • Crushing Chest Pain
  • Anxiety or restlessness
  • Sudden, severe, SOB
  • Weakness
  • Nausea

Objective Data:

Patient may have any combination of these signs depending on the cause of their cardiogenic shock

  • Evidence of MI or 12-Lead and Cardiac Enzymes
  • ↑ HR
  • ↑ RR
  • ↓ BP
  • ↓SpO2
  • ↓ Temp
  • ↑ CVP
  • ↓ CO
  • ↑ SVR
  • ↓ LOC
  • ↓ Urine output
  • Skin is cold, pale, possibly dusky or mottled
  • Pulses rapid and thready
  • Diaphoretic
  • JVD
  • Crackles in lungs
  • Heart sounds muffled
  • S3, S4 present

Nursing Interventions and Rationales:

  1. Assess for Risk: History of Myocardial Infarction, Coronary Artery Disease, Obesity, Hyperlipidemia, Pulmonary Embolism Risk, Blunt Chest Trauma
    • Nurses should assess their patient for the risk of developing cardiogenic shock.

      History of MI - previous damage to heart muscle means more susceptible to shock with a recurrent MI.

      CAD, Obesity, HLD all contribute to risk for MI

      Pts on prolonged bedrest, postpartum mothers, and those with DVTs are at highest risk of developing a pulmonary embolism

      Blunt Chest Trauma means patient may be at risk of developing pericardial tamponade.

      Either way, the more aware the nurse is of the risk, the more likely it can be prevented or caught early.
  2. Assess and monitor: VS - apply oxygen as needed, LOC Lung Sounds, Edema, Urine Output
    • Monitoring VS could help to prevent decompensation and cardiac arrest if caught early, but will also help to determine the patient’s response to treatment.

      Level of consciousness should be assessed because it may decrease as the patient loses oxygenation of their brain. Decreasing LOC is a sign of advancing shock.

      If a patient’s SpO2 falls below 92% (or prescribed threshold), apply supplemental oxygen via nasal cannula to improve overall oxygenation ability.
  3. Assess and manage pain
    • Patient may have severe chest pain because of myocardial ischemia. Pain should be assessed every 4 hours or more often as needed, and reassessed 30 minutes after administration of pain medication.
  4. Monitor Hemodynamics: MAP, CVP, CO, SVR, VO2
    • Hemodynamic measurements will tell us the severity of the shock and how well the patient is responding to treatment.

      MAP = Mean Arterial Pressure - this is the average pressure within the arteries. It can be calculated with a non-invasive blood pressure, but is more accurate when measured by an Arterial Line. Decompensated shock will show a decreasing MAP below 60 mmHg

      CVP = Central Venous Pressure. This measures Preload. In a patient with cardiogenic shock, it will be high (>12 mmHg). The goal would be to see this number return closer to normal, but ultimately the CO measurement is more important.

      CO = Cardiac Output. In cardiogenic shock, the overall CO takes the biggest hit. The body cannot compensate. The goal of therapy is to increase cardiac output, so it needs to be monitored closely. This is assessed using a FloTrac or Pulmonary Artery catheter.

      SVR = Systemic Vascular Resistance. This measures afterload. We will expect this to be high because of the body’s attempts to compensate through vasoconstriction. If treatment is effective, we will see this number return back down to normal. Dobutamine can also help to decrease this number through vasodilation.

      VO2 Oxygen consumption - the rate at which oxygen is taken up into the tissues. In cardiogenic shock, we will see this number decrease significantly because the tissues are not getting the oxygen they need. This is a classic sign of cardiogenic shock versus heart failure (normal VO2)
      (Marino, 2007)
  5. Calibrate all hemodynamic monitoring transducers: Level and Zero CVP and A-line to the phlebostatic axis
    • The phlebostatic axis is located at the 4th intercostal space, mid-axillary line and is the most accurate reference point for the right atrium. This is where a CVP is measured using a central line. It is also the most accurate reference point of the aorta for MAP measured by an arterial line.

      Levelling and zeroing ensures that the measurements are calibrated correctly so that readings are accurate.
  6. Prepare for procedures: Arterial Line or Central Line Placement, Gather all supplies, Ensure consent is obtained by provider, Explain procedure to patient/family, Prep fluids or tubing, Ensure all monitoring equipment is available Intubation Notify Respiratory Therapist and Charge Nurse for support, Suction and Ambu Bag at the bedside, Gather supplies, Ensure all monitoring equipment is available, Surgical Intervention, Follow facility procedures, Remove all personal clothes, jewelry, etc., Ensure informed consent is obtained by provider, Facilitate transport
    • Arterial lines are placed for invasive hemodynamic monitoring. They can measure MAP, but can also measure other hemodynamic values such as CO/CI, SVR, SV, etc. when using a FloTrac machine.

      Central lines are placed for administration of fluids and medications as well as hemodynamic monitoring of CVP, CO/CI, and SVR. Patients with cardiogenic shock may also receive a Pulmonary Artery catheter (also called a Swan-Ganz catheter) for more detailed invasive hemodynamic monitoring.

      Patients whose airway and/or ventilation has been compromised due to ↓ LOC or pulmonary edema may need to be intubated and placed on a ventilator.

      Patients may need to be taken to the OR to repair the injury or internal bleeding that caused the hypovolemia in the first place.

      **Informed consent MUST be obtained by the provider. You can explain procedures to patients/family, but the provider must give the reason, risks, benefits, etc. and obtain the informed consent.
  7. Maintain HOB >30°
    • Lowering the head of bed or laying the patient flat can be detrimental for two reasons:

      It brings blood towards the heart and baroreceptors, which will now believe that the problem has been fixed and will stop working to compensate. While lowering the head and raising the legs can be useful in the absence of other interventions, it should be avoided once more advanced therapies are available.

      The patient likely has pulmonary edema because of this acute cardiogenic shock. Laying them flat will compromise their oxygenation because of all the fluid in their lungs.
  8. Elevate legs on pillows Apply SCD’s SCD’s are contraindindicated if the patient already has a DVT
    • The goal with these interventions is to decrease peripheral edema in the patient’s legs and facilitate some venous return in order to prevent development of a DVT. DVT’s are the #1 cause of pulmonary embolism.
  9. Prepare for and manage Intra-Aortic Balloon Pump (IABP): Prep like any other procedure Leg used should be kept straight at all times, Patient on bedrest - reposition every 2 hours, Follow facility policy for documentation of pressures
    • This is an advanced technique that would be seen in a cardiovascular ICU. IABP is used to decrease the workload/afterload on the heart and assist with forward circulation. It is inserted via the femoral artery into the descending aorta. The balloon inflates during diastole to help with filling pressures and deflates with systole to help with forward pressure.

      Advanced cardiogenic shock may require LVAD or Transplant.

References

Date Published - Oct 29, 2018
Date Modified - Nov 9, 2018