Nursing Case Study for Cardiogenic Shock
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Outline
Betty is a 71-yr-old woman with a history of high blood pressure, diabetes, and acute myocardial infarction 2 years ago. She has complained of chest pain with nausea and fatigue at her nursing home and, per protocol, an EKG was done in the ambulance on her way to the local ER. The ER provider interprets the EKG as having significant ST-segment elevation in the anterior leads and he mentions Q waves as well.
The nurse should initiate what protocol with this information? Why?
What signs and symptoms did Betty have that caused the staff of the nursing home to call 911?
Vital signs as follows prior to the patient being taken to the cath lab:
BP 80/50 mmHg SpO2 91% on 2 L NC
HR 111 bpm with frequent PVCs on monitor
RR 32 bpm at rest
Temp 37°C
She also complains of “having trouble breathing” and has a look of fear and worry on her face. She is placed on the portable monitor to go to the cath lab and the nurse notices that the cardiac rhythm is very fast, approx. 180 bpm. There appear to be no P waves anymore and the QRS is very wide. The monitor alarms loudly and Betty’s eyes are now closed.
How does the nurse interpret this rhythm? What should she do first?
The ACLS team begins resuscitation of Betty, and she does not appear to be breathing either. The ER provider initiates rapid sequence intubation, and an endotracheal tube is placed. Respiratory therapy brings a ventilator to assist with the patient’s respirations. She is taken to the cath lab.
What does the nurse think the cardiac catheterization will show?
Betty’s family waits in the ER because they are requesting, she be sent to a larger hospital for open-heart surgery. The patient will come back to the ER instead of being admitted to the small ICU. The cath lab calls with a report and confirms the nurse’s suspicions of blocked coronary arteries and she has an EF of only 15% indicating heart failure.
Are there devices to help Betty’s heart ineffective pumping (similar to the ventilator to help her breathe)?
Betty’s urinary catheter reveals scant, dark urine. Her extremities are cool to the touch. She is sedated for the ventilator support but when sedation is paused for assessment, she does not wake up at all.
What signs of shock is Betty exhibiting? What other clues does the nurse have indicating this could be cardiogenic shock?
Her family asks why she is not being transferred right away.
How can the nurse best explain the situation to the family?
Another staff member interrupts the nurse during her discussion with the family to say that Betty’s MAP is only 50.
How does the nurse interpret this number? How is it calculated?
What type of medication might the nurse request from the provider or ask about starting?
The nurse prepares to call in a report to a larger facility to transfer Betty. The family asks what to expect “from all of this.”
How can the nurse explain the course of treatment to the family?
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Transcript
Hey everyone. My name is Abby. We’re going to go through a case study regarding cardiogenic shock. Let’s get started. In this scenario, Betty is a 71-year-old woman with a history of high blood pressure, diabetes and two years ago, she had an MI. She has complained of chest pain with nausea and fatigue at her nursing home and per protocol, an EKG was performed in the ambulance on the way to her local ER. The ER provider interprets the EKG as having significant ST Elevation in the anterior leads. He also mentions Q waves. Now, let’s take a look at critical thinking checks number one and number two below.
Great job. The vital signs were taken in the cath lab. Let’s take a look at them:
Her blood pressure was 80 over 50. She had a heart rate of 111 beats per minute, but she was also having some ectopy with pre-ventricular contractions. Her respiratory rate was 32 breaths per minute at rest and her temperature, 37 degrees Celsius on two liters nasal cannula. She was saturating at 91%. She also complains of having trouble breathing. She has a look of fear and worry on her face. She’s placed on the portable monitor to go to the cath lab and the nurse notices that the cardiac rhythm is very fast, approximately 180 beats per minute. It’s very tachy. There appear to be no P waves anymore and the QRS complex is very wide. The monitor alarms loudly and Betty’s eyes are now closed. Now that we have these results, let’s take a look at critical thinking check number three below.
Excellent. The ACLS team begins resuscitation of Betty, and she does not appear to be breathing. The ER provider initiates rapid sequence intubation and an endotracheal tube is placed. Respiratory therapy brings a ventilator to assist with the patient’s respirations. She’s taken back to the cath lab. Now that we have this information, let’s take a look at critical thinking check number four below.
Wonderful job. Betty’s family has been waiting in the ER because they’re requesting that she be sent to a larger hospital for open heart surgery. The patient will come back to the ER instead of being admitted to the small ICU, the cath lab calls with a report and confirms the nurse’s suspicion of blocked coronary arteries. And she has an ejection for action of only 15% indicating heart failure. Now that we know this, let’s take a look at critical thinking. Check number five below.
Well done. Betty’s urinary catheter reveals scant, dark urine. Her extremities are cool to the touch. She is sedated for ventilator support, but when sedation is paused, she doesn’t wake up at all. Now that we know this information, let’s take a look at critical thinking check number six.
Great work. Her family asks why she’s not being transferred right away. Let’s take a look at critical thinking check number seven below and see what’s up.
Nicely done. Another staff member interrupts the nurse during her discussion with the family to let the nurse know that Betty’s map is only 50. Now that we have this information, let’s take a look at critical thinking checks number eight and number nine below.
Well done, the nurse prepares to call in a report to a larger facility to transfer Betty. The family asks what to expect from all of this. We know that families like to ask questions. Now that we have this, let’s take a look at critical thinking check number 10 below.
Great job you guys, that wraps up the case study on cardiogenic shock. Please take a look at the attached study tools and test your knowledge with a practice quiz. We love you all,now go out and be your best self today and as always, happy nursing!
References:
Clinical manifestations and diagnosis of cardiogenic shock in acute myocardial infarction
Author:Alex Reyentovich, MD, updated Jan, 2020, Overview of the acute management of ST-elevation myocardial infarction
Authors:Guy S Reeder, MDHarold L Kennedy, MD, MPH updated Mar, 2021; Use of vasopressors and inotropes
Author:Scott Manaker, MD, PhD updated Nov, 2021
https://www.ahajournals.org/doi/full/10.1161/JAHA.119.011991
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Nursing Case Studies
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.
We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.