Jugo, Kate Guillan A.

Lavadia, Dorothy Rose D.

ASSESSMEN NURSING
PLANNING DIAGNOSTICS RATIONALE INTERVENTION RATIONALE EVALUATION
T DIAGNOSIS
Subjective: Cardiogenic Short term: 1. 12-lead 1. Detect the Independent: Short term:
 Occupation: Shock related After 8 hours of ECG electrical 1. Monitor blood 1. Alteration in blood After 8 hours of
electrician to Tachy- nursing activity of the pressure, apical pulse, pressure and differences nursing intervention,
 Unconsciou arrhythmia intervention, the heart and peripheral pulses. in equality, rate, and the patient:
s w/ labored patient will: measure the regularity of pulses are  Manifested
breathing  Manifest timing and indicative of the effect of normal cardiac
 Erythemato normal duration of altered cardiac output on rhythm as
us face cardiac each electrical systemic/peripheral evidenced by a
 Singed rhythm as phase in your circulation. normal 12-lead
eyebrows, evidenced by heartbeat. 2. Monitor vitals signs. 2. Although not all ECG reading
eyelashes a normal 12- 2. To record the Assess adequacy of dysrhythmias are life-  Was free from
and hair lead ECG 2. Holter heart's activity cardiac output/ tissue threatening, immediate signs of
 Thick white reading monitor as one goes perfusion, noting treatment may be cardiogenic
leathery  Be free from about their significant variations in required to terminate shock.
eschar on signs of routine for a BP/pulse rate equality, dysrhythmia in the
the whole cardiogenic long period of respirations, changes in presence of alterations in Long term:
upper shock. time. skin color/temperature, cardiac output and tissue After 3 weeks of
extremities 3. Measure level of perfusion. nursing intervention,
 Blisters on Long term: 3. Blood amounts of consciousness/sensoriu the patient:
anterior After 3 weeks chemistry certain m, and urine output  Maintained
chest and of nursing test chemicals in a during episodes of adequate cardiac
neck intervention, the sample of dysrhythmias. output as
patient will: blood, 3. Investigate reports of 3. Reasons for chest pain evidenced by BP
 Nausea
 Maintain especially chest pain, are variable and depend and pulse within
adequate serum documenting location, on underlying cause. normal range,
Objective:
cardiac potassium, duration, intensity (0- However, chest pain may adequate urinary
 HR: 142
output as calcium, 10 scale), and indicate ischemia due to output, palpable
bpm
evidenced by magnesium relieving/ aggravating altered electrical pulses of equal
 BP: 80/50 and sodium. factors. Note nonverbal conduction, decrease
BP and pulse quality, normal
 Hgb: 20 g/dl 4. Records the pain cues (e.g. facial myocardial perfusion, or
within normal level of
 Hct: 52% 4. Electrocardi electrical grimacing, crying). increased oxygen need.
range, consciousness
 Na: 150 ogram activity of your 4. Be prepared to initiate 4. Development of life-
adequate  Displayed
mEq/L; urinary heart via cardiopulmonary threatening dysrhythmias absence of
126mEq/L output, electrodes resuscitation (CPR) as requires prompt dysrhythmias.
 K: 3.2 attached to indicated. intervention to prevent
 mEq/L; palpable your skin. If ischemic damage/death.  Displayed no
6 mEq/L pulses of you have 5. Prepare for procedures: 5. Arterial lines are placed recurrence of
 Pain: 10/10 equal quality, damaged heart Arterial Line or for invasive cardiogenic shock
 Decreased normal level muscle, Central Line hemodynamic  Restored
urine output of electric Placement, Gather all monitoring. They can sufficient cardiac
consciousnes problems or supplies, Ensure measure MAP, but can output to the
s fluid buildup consent is obtained by also measure other tissues.
 Display around your provider, Explain hemodynamic values
absence of heart, it won't procedure to such as CO/CI, SVR, SV,
dysrhythmias. conduct patient/family, Prep etc. when using a
 Display no electrical fluids or tubing, Ensure FloTrac machine.
recurrence of impulses all monitoring Central lines are
cardiogenic normally. equipment is available placed for administration
shock 5. Cardiac 5. To check the Intubation Notify of fluids and medications
 Restore Catheterizati amount of Respiratory Therapist as well as hemodynamic
sufficient on blood your and Charge Nurse for monitoring of CVP,
cardiac heart is support, Suction and CO/CI, and SVR. Patients
output to the pumping with Ambu Bag at the with cardiogenic shock
tissues. each beat bedside, Gather may also receive a
(cardiac supplies, Ensure all Pulmonary Artery
output). monitoring equipment catheter (also called a
is available, Surgical Swan-Ganz catheter) for
Intervention, Follow more detailed invasive
facility procedures, hemodynamic
Remove all personal monitoring.
clothes, jewelry, etc., Patients whose airway
Ensure informed and/or ventilation has
consent is obtained by been compromised due to
provider, Facilitate ↓ LOC or pulmonary
transport 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.
Dependent: 1. Dysrhythmias are
1. Give the drug as generally treated
indicated such as symptomatically
intropic agents and
anti-dysrhythmias.  You might be given
 Inotropic Agents medications to improve
your heart function, such
as epinephrine
(Levophed) or dopamine,
until other treatments
start to work.
 For systemic
 Epinephrine (0.05- vasoconstriction and to
0.5mcg/kg/min) address tachycardia and
hypotension
2. For homeostasis and
2. Administer IV fluids as future administration of
ordered. emergency drugs.
3. Increases amount of
3. Administer oxygen available for
supplemental oxygen myocardial uptake,
as indicated. which decreases
irritability caused by
hypoxia.
Collaborative:
1. Monitor 1. Hemodynamic
Hemodynamics: MAP, measurements will tell us
CVP, CO, SVR, VO2 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
2. Monitor and refer VO2)
laboratory results: 2.
 Electrolytes
 Imbalance of
electrolytes, such as
potassium, and
calcium adversely
affects cardiac rhythm
 Drug levels and contractility.
 Reveal therapeutic/
toxic level of
prescription
medications or street
 drugs that may affect/
contribute to presence
3. Insert and maintain IV of dysrhythmias.
access. 3. Patent access line may be
required for
administration of
4. Prepare for the emergency drugs.
instillation of 4. Anticipation for possible
cardioversion machine occurrence of emergency
or defibrillator. cardiac dysrhythmias that
may lead to shock.

References:
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arrhythmia.
Electrical Injuries in Emergency Medicine Clinical Presentation. (2018, September 04). Retrieved from https://emedicine.medscape.com/article/770179-clinical#b2.
Heart arrhythmia. (2017, December 27). Retrieved from https://www.mayoclinic.org/diseases-conditions/heart-arrhythmia/diagnosis-treatment/drc-20350674.
Nursing Care Plan for Heart Rhythm Disorders: Arrhythmia. (n.d.). Retrieved from http://nanda-diagnosis.blogspot.com/2015/04/nursing-care-plan-for-heart-rhythm.html.
Ventricular Dysrhythmias | Nursing Central. (n.d.). Retrieved from https://nursing.unboundmedicine.com/nursingcentral/view/Diseases-and-
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