Nursing Care Plan (NCP) for Cardiogenic Shock
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Outline
Lesson Objective for Cardiogenic Shock Nursing Care Plan
- Understanding Cardiogenic Shock:
- Gain a comprehensive understanding of cardiogenic shock, including its pathophysiology, etiology, and associated risk factors.
- Recognition of Clinical Manifestations:
- Develop the ability to recognize and interpret the clinical manifestations of cardiogenic shock, distinguishing them from other forms of shock.
- Implementation of Interventions:
- Acquire the skills to implement timely and appropriate nursing interventions aimed at stabilizing the patient, improving cardiac output, and addressing the underlying causes of cardiogenic shock.
- Monitoring and Assessment:
- Learn effective monitoring techniques and assessment strategies to evaluate the patient’s response to interventions, hemodynamic status, and overall progress during the treatment of cardiogenic shock.
- Collaborative Team Communication:
- Develop strong communication skills for collaboration with the healthcare team, ensuring seamless coordination of care, and promoting optimal outcomes for patients experiencing cardiogenic shock.
Pathophysiology of Cardiogenic Shock
- Impaired Cardiac Function:
- Cardiogenic shock is primarily characterized by a severe decrease in cardiac output, resulting from impaired myocardial contractility. This dysfunction can stem from conditions such as myocardial infarction, severe heart failure, or myocardial contusion.
- Decreased Tissue Perfusion:
- Inadequate cardiac output leads to diminished perfusion of vital organs and tissues, depriving them of oxygen and nutrients. This can trigger a cascade of cellular events, contributing to multiorgan dysfunction.
- Increased Myocardial Workload:
- The heart attempts to compensate for decreased cardiac output by increasing its workload. This compensatory mechanism can exacerbate myocardial ischemia and further compromise the heart’s ability to pump effectively.
- Activation of Neurohormonal Responses:
- The body initiates neurohormonal responses, including the release of catecholamines (such as adrenaline) and activation of the renin-angiotensin-aldosterone system. While initially adaptive, prolonged activation can lead to detrimental effects on the cardiovascular system.
- Systemic Inflammatory Response:
- Cardiogenic shock can trigger a systemic inflammatory response, contributing to endothelial dysfunction and promoting the release of inflammatory mediators. This inflammatory state further compounds organ damage and dysfunction.
Etiology of Cardiogenic Shock
- Myocardial Infarction (MI):
- A leading cause of cardiogenic shock, MI results from a sudden reduction or blockage of blood flow to a part of the heart muscle, leading to myocardial damage and compromised cardiac function.
- Severe Heart Failure:
- Advanced stages of heart failure, where the heart is unable to pump blood effectively, can progress to cardiogenic shock. This may be due to chronic conditions such as ischemic heart disease or cardiomyopathy.
- Myocardial Contusion:
- Trauma or injury to the chest, such as in a severe accident or blunt force trauma, can cause myocardial contusion, leading to impaired cardiac function and potentially cardiogenic shock.
- Cardiomyopathy:
- Conditions affecting the heart muscle, such as dilated or hypertrophic cardiomyopathy, can contribute to cardiogenic shock by compromising the heart’s ability to contract and pump blood adequately.
- Arrhythmias:
- Certain severe arrhythmias, especially those leading to sustained ventricular tachycardia or fibrillation, can disrupt the heart’s normal rhythm, impairing its pumping function and precipitating cardiogenic shock.
Desired Outcome of Cardiogenic Shock Management
- Stabilize Hemodynamics:
- Achieve and maintain hemodynamic stability by optimizing blood pressure, heart rate, and cardiac output to ensure adequate organ perfusion.
- Restore Myocardial Perfusion:
- Implement interventions to restore blood flow to the myocardium, such as reperfusion therapies like angioplasty or thrombolytics in the case of ischemic causes.
- Optimize Oxygenation:
- Ensure optimal oxygen delivery to tissues by improving respiratory function and supporting oxygenation through mechanical ventilation if necessary.
- Address Underlying Cause:
- Identify and treat the underlying cause of cardiogenic shock, whether it be myocardial infarction, severe heart failure, or other contributing factors.
- Prevent Complications:
- Mitigate and prevent complications associated with cardiogenic shock, such as multiorgan failure, by providing comprehensive care, including renal support, nutritional support, and vigilant monitoring.
Cardiogenic Shock Nursing Care Plan
Subjective Data:
- Crushing Chest Pain
- Anxiety or restlessness
- Sudden, severe, SOB
- Weakness
- Nausea
Objective Data:
- 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 Assessment for Cardiogenic Shock
- Hemodynamic Monitoring:
- Continuously monitor blood pressure, heart rate, and central venous pressure to assess the patient’s hemodynamic status.
- Cardiac Rhythm Analysis:
- Perform continuous electrocardiogram (ECG) monitoring to identify arrhythmias or changes in cardiac rhythm.
- Assessment of Respiratory Status:
- Monitor respiratory rate, effort, and oxygen saturation to assess the adequacy of oxygenation and ventilation.
- Neurological Assessment:
- Evaluate the patient’s level of consciousness, neurological status, and responsiveness to stimuli for signs of cerebral hypoperfusion.
- Peripheral Perfusion Assessment:
- Assess peripheral perfusion by monitoring skin color, temperature, and capillary refill time to identify signs of poor tissue perfusion.
- Fluid Balance Monitoring:
- Keep track of intake and output to assess fluid balance, considering the patient’s response to fluid resuscitation.
- Laboratory Values:
- Monitor laboratory values, including arterial blood gases, electrolytes, and cardiac enzymes, to evaluate organ function and guide treatment.
- Pain Assessment:
- Assess and manage pain, considering the potential for ischemic chest pain and the need for pain relief to reduce cardiac workload.
- Psychosocial Assessment:
- Consider the emotional and psychological impact of cardiogenic shock on the patient and their family, offering support and resources as needed.
Implementation for Cardiogenic Shock
- Hemodynamic Support:
- Administer vasoactive medications, such as inotropes, to improve cardiac contractility and optimize blood pressure.
- Administer medications, such as antiarrhythmics, to correct underlying arrhythmias.
- Oxygen Therapy:
- Provide supplemental oxygen to ensure adequate oxygenation and relieve myocardial oxygen demand. Critically ill patients may require mechanical ventilation. Collaborate with respiratory therapy as needed.
- Fluid Management:
- Administer intravenous fluids cautiously to maintain adequate preload while avoiding fluid overload and pulmonary edema.
- Monitor urine output as an indicator of fluid balance and organ perfusion.
- Pain Management:
- Administer appropriate analgesics to manage chest pain and reduce the overall cardiac workload.
- Continuous Monitoring:
- Implement continuous monitoring of vital signs, ECG, and invasive hemodynamic parameters to assess the patient’s response to interventions.
Nursing Interventions and Rationales
- 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.
- 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.
- 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.
- 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)
- 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.
Leveling and zeroing ensures that the measurements are calibrated correctly so that readings are accurate.
- 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 Line or Central Line Placement
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.
- 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.
- 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.
- 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.
Evaluation for Cardiogenic Shock
- Hemodynamic Parameters:
- Regularly assess and analyze hemodynamic parameters, including blood pressure, heart rate, and central venous pressure, to evaluate the effectiveness of vasoactive medications and fluid management.
- Organ Perfusion:
- Monitor for signs of adequate organ perfusion, such as mean arterial pressure > 60, urine output 0.5 – 1.5 ml/kg/hr
- Oxygenation Status:
- Monitor oxygen saturation levels and arterial blood gases to ensure adequate oxygenation and assess the impact of oxygen therapy.
- Pain Assessment:
- Evaluate the patient’s pain level and assess the effectiveness of pain management strategies to ensure optimal comfort.
- Fluid Balance:
- Review fluid balance and assess for signs of fluid overload or depletion, adjusting intravenous fluid administration as needed.
- Clinical Response:
- Evaluate the overall clinical response, including the resolution or improvement of symptoms such as chest pain and dyspnea, to determine the success of the nursing care plan.
References
- https://www.nhlbi.nih.gov/health-topics/cardiogenic-shock
- https://emedicine.medscape.com/article/152191-medication
- https://emedicine.medscape.com/article/152191-clinical
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Transcript
This lesson, we’re going to take a look at the care plan for cardiogenic shock. So, we’ll briefly take a look at the path of physiology and etiology of this issue.
We’re also going to take a look at additional things like subjective and objective data that your patient may present with as well as nursing interventions and rationales for this issue.
Alight, let’s jump in. So, the medical diagnosis is cardiogenic shock, which is an acute and extreme version of heart failure, where the organs are not receiving adequate oxygenated blood. So guys, cardiogenic shock is most definitely a medical emergency. It can be caused by a few things like myocardial infarction or MI, because of the heart’s inability to pump effectively, also issues that obstruct blood flow like cardiac tamponade, which is a buildup of fluid around the heart, which compresses and prevents functional pumping. Also a pulmonary embolism or PE, a blood clot in the pulmonary arteries can prevent blood flow and also cause cardiogenic shock.
So the desired outcome for a patient with this issue is to reverse what is causing the problem and restore sufficient cardiac output. So let’s take a look at some of the subjective and objective data that your patient with this issue may present with.
Now, remember subjective data. These are going to be things that are based on your patient’s opinions or feelings. So, they may include the feeling of crushing chest pain. Also, they might express anxiousness or restlessness, sudden and severe shortness of breath, weakness, or maybe nausea.
Objective data are a number of things, including the evidence of an EMI increased heart rate, increased respiratory rate, decreased blood pressure, decreased oxygen saturation, decreased temperature, increased central venous pressure and decreased cardiac output. Your patient’s heart sounds. They may sound muffled. They may have decreased urine output or crackles in the lungs. They may have a rapid, thready pulse and they may be diaphoretic with cold/ pale, possibly mottled skin.
Okay, nursing interventions are a super important part of a care plan. So, let’s take a look at a few of those for cardiogenic shock. First off, assess your patient’s risk for developing this issue. Things like a history of an EMI means your patient is more susceptible because of previous damage to the heart. So, coronary artery disease, obesity, and hyperlipidemia all contribute to the risk of having an EMI. So, assess your patient’s risk also for a pulmonary embolism. Those on prolonged bed rest, postpartum mothers and patients with DVT are all at a higher risk. Finally, blunt chest trauma puts the patient at risk of developing pericardial tamponade.
Being aware of these risk factors in your patient means cardiogenic shock can be prevented or caught early okay? So, for cardiogenic shock, you will monitor vital signs to prevent decompensation or cardiac arrest, applying oxygen as needed and as necessary, monitor level of consciousness because decreased LOC is a sign of advancing shock. Also assess lung sounds, edema and your patient’s urine output.
A few more nursing interventions for this issue are assessing your patient’s pain and managing that pain. So, your patient may have severe chest pain because of myocardial ischemia. So, pain should be assessed every four hours or even more often. And of course, reassess 30 minutes after you give any pain meds.
So, for monitoring hemodynamics, it is critical. It will tell us as providers how severe the shock is and if the patient is responding to treatment. Mean arterial pressure or MAP is the average pressure in the arteries. Decompensating shock will show a decreasing map below 60 millimeters of mercury. Central venous pressure means preload in a patient with cardiogenic shock. This pressure will be greater than 12 millimeters of mercury cardiac output and is super important because in cardiogenic shock, cardiac output takes the biggest hit.
So, the goal is to increase cardiac output. This can be measured by the use of a flow track or pulmonary artery catheter. Also, with systemic vascular resistance or SVR, we can expect this to be high because the body will try to compensate with vasoconstriction. So, we watch this value because it will return to normal. If treatment is effective, guys dobutamine can also help to decrease this number. Finally, V02 oxygen compensation, which is the rate at which oxygen is taken up into the tissues is decreased in shock. So, this is a classic sign of cardiogenic shock versus heart failure where V02 is normal. Okay, hemodynamic monitors, they must be calibrated for accurate readings. They must be leveled and zeroed at the phlebostatic axis, which is located at the fourth intercostal space, mid axillary line. This is the most accurate reference point for the right atrium and where the CVP is measured using a central line.
Guys, this is also the most accurate reference point of the aorta for MAP being measured with an arterial line. Be sure to prepare your patient for any possible procedures, like an art line or central line placement for intubation or a surgical intervention. To prepare for the arterial line placement, gather supplies, ensure consent is obtained by the provider, explain the procedure to the patient and family and prep any fluids or tubing, and ensure monitoring equipment is available.
Guys, if the patient has a decreased level of consciousness or compromised ventilation, intubation may be necessary. Make sure supplies, including an ambu bag are available and notify respiratory therapy or the charge nurse for support. So for surgical interventions, possibly to repair an injury or internal bleeding, follow your facility’s protocol, remove all jewelry from your patient, clothing, obtain informed consent, and also, this is by the provider, and possibly, facilitate transport.
So, it may sound super simple, but it’s critical that with a patient with cardiogenic shock, the head of the bed must be greater than 30 degrees. The reason for this is a patient with this issue that lays flat or lowering the head of the bed can be detrimental to the patient’s laying flat, brings blood to the heart and barrier receptors, which will make the body think that the problem has been fixed and compensation will then be stopped. So, it is important to say that in some cases, lowering the head and raising the legs can help if there is an absence of other interventions, but not when we have more advanced therapies available. Also guys, patients with acute cardiogenic shock commonly have pulmonary edema. So, laying them flat compromises their oxygenation. Elevating the patient’s legs and applying SCDs helps to decrease peripheral edema and also facilitates venous return to prevent DVTs.
DVTs are the number one cause of PEs. Remember though, SCDs are contra-indicated to any patient with a current DVT.
A final intervention is to repair and manage the intra aortic balloon pump or IABP, which is an advanced technique that is typically seen in the cardiovascular ICU. The IABP is used to decrease workload afterload on the heart and with forward circulation. The IABP is inserted through the femoral artery, into the descending aorta. This IABP, it inflates during diastolic to help with filling pressures and deflates with systolic for pressure. So, to prepare for this, prep like any other procedure, but after, the legs should be kept straight at all times. The patient should be on bedrest and repositioned every two hours and finally, follow facility policy for documentation of their pressures. One final thing guys, some patients may even require an LVAD or even a heart transplant.
Okay, here is a look at the final care plan for cardiogenic shock. Alright, let’s do a quick review. Cardiogenic shock occurs due to organs not receiving adequate oxygenated blood due to heart failure, which is sudden acute and a medical emergency. Causes include an MI, cardiac tympanum or a pulmonary embolism. Subjective data is crushing chest pain, anxiety, restlessness, shortness of breath, weakness and nausea. Objective data can include decreased BP, SATs, temperature, cardiac output, level of consciousness, increased heart rate, respiratory rate or CVP. Assess your patient’s risk, monitor vital signs, level of consciousness, lung sounds, edema, their hemodynamics as well as their pain. Calibrate hemodynamic monitors, prepare for any procedures, elevate the head greater than 30 degrees. On the legs, apply SCDs, prepare and manage the inner aortic balloon pump.
Okay guys, that is it on this care plan, go out and be your best self today and as always, happy nursing!
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