Nursing Care Plan (NCP) for Cardiogenic Shock

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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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