Nursing Care Plan (NCP) for Cardiogenic Shock

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

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

• Assess and monitor:
  • VS – apply oxygen as needed
  • LOC
  • Lung Sounds
  • Edema
  • Urine Output

• Assess and manage pain

• Monitor Hemodynamics
  • MAP
  • CVP
  • CO
  • SVR
  • VO2

• Calibrate all hemodynamic monitoring transducers: Level and Zero CVP and A-line to the phlebostatic axis

• 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

• Maintain HOB >30°

• Elevate legs on pillows
  Apply SCD’s
  SCD’s are contraindindicated if the patient already has a DVT

• 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

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