Nursing Assessment

 Identify patients at risk for development of cardiogenic shock.

 Assess for early signs and symptoms indicative of shock:
o Restlessness, confusion, or change in mental status
o Increasing heart rate
o Decreasing pulse pressure (indicates impaired CO)
o Presence of pulses alternans (indicates left-sided heart failure)
o Decreasing urine output, weakness, fatigue
 Observe for presence of central and peripheral cyanosis.
 Observe for development of oedema.
 Identify signs and symptoms indicative of extension of MI recurrence of chest pain,
diaphoresis.
 Identify patient's and significant other's reaction to crisis situation.

NURSING ALERT
Cardiogenic shock carries an extremely high mortality. Astute assessments and immediate
actions are essential in preventing death.

Nursing Diagnoses

 Decreased Cardiac Output related to impaired contractility due to extensive heart

muscle damage
 Impaired Gas Exchange related to pulmonary congestion due to elevated left
ventricular pressures
 Ineffective Tissue Perfusion (renal, cerebral, cardiopulmonary, GI, and peripheral)
related to decreased blood flow
 Anxiety related to intensive care environment and threat of death

Nursing Interventions

1.Improving Cardiac Output

 Establish continuous ECG monitoring to detect dysrhythmias, which increase

myocardial oxygen consumption.
 Monitor hemodynamic parameters continually with Swan-Ganz catheter (see page
342) to evaluate effectiveness of implemented therapy.
o Obtain pulmonary artery pressure (PAP), PCWP, and CO readings as
indicated.
o Calculate the CI (CO relative to body size) and SVR (measurement of
afterload).
o Cautiously titrate vasoactive drug therapy according to hemodynamic
parameters.
 Be alert to adverse responses to drug therapy.
o Dopamine (Intropin) may cause increase in heart rate.
o Vasodilators nitroglycerin (Tridil) and nitroprusside (Nipride) may worsen
hypotension.
o Digoxin (Lanoxin) may result in dysrhythmias from toxicity.
 o Diuretics may cause hyponatremia, hypokalemia, and hypovolemia.
 Administer vasoactive drug therapy through central venous access (peripheral tissue
necrosis can occur if peripheral I.V. access infiltrates, and peripheral drug distribution
may be lessened from vasoconstriction).
 Monitor BP and mean arterial pressure (MAP) with intra-arterial line (cuff pressures
are difficult to ascertain and may be inaccurate) every 5 minutes during active
titration of vasoactive drug therapy; otherwise, monitor every 30 minutes.
 Maintain MAP greater than 60 mm Hg (blood flow through coronary vessels is
inadequate with a MAP less than 60 mm Hg).
 Measure and record urine output every hour from indwelling catheter and fluid intake.
 Obtain daily weight.
 Evaluate serum electrolytes for hyponatremia and hypokalemia.
 Be alert to incidence of chest pain (indicates myocardial ischemia and may further
extend heart damage).
o Report immediately.
o Obtain a 12-lead ECG.
o Anticipate use of counterpulsation therapy.

2.Improving Oxygenation

 Monitor rate and rhythm of respirations every hour.

 Auscultate lung fields for abnormal sounds (coarse crackles indicate severe
pulmonary congestion) every hour; notify health care provider.
 Evaluate arterial blood gas (ABG) levels.
 Administer oxygen therapy to increase oxygen tension and improve hypoxia.
 Elevate head of bed 20 to 30 degrees as tolerated (may worsen hypotension) to
facilitate lung expansion.
 Reposition patient frequently to promote ventilation and maintain skin integrity.
 Observe for frothy pink sputum and cough (may indicate pulmonary edema); report
immediately.

3.Maintaining Tissue Perfusion

 Perform a neurologic check every hour, using the Glasgow Coma Scale.
 Report changes immediately.
 Obtain BUN and creatinine blood levels to evaluate renal function.
 Auscultate for bowel sounds every 2 hours.
 Evaluate character, rate, rhythm, and quality of arterial pulses every 2 hours.
 Monitor temperature every 2 to 4 hours.
 Use sheepskin foot and elbow protectors to prevent skin breakdown.

4.Relieving Anxiety

 As with the above, always evaluate signs of increasing anxiety and/or new onset
anxiety for a physiologic cause before treating with anxiolytics.
  Explain equipment and rationale for therapy to patient and family. Increasing
knowledge assists in alleviating fear and anxiety.
 Encourage patient to verbalize fears about diagnosis and prognosis.
 Explain sensations patient will experience before procedures and routine care
measures.
 Offer reassurance and encouragement.
 Provide for periods of uninterrupted rest and sleep.
 Assist patient to maintain as much control as possible over environment and care.
o Develop a schedule for routine care measures and rest periods with patient.
o Make sure that a calendar and clock are in view of patient.

5.Patient Education and Health Maintenance

 Teach patients taking digoxin (Lanoxin) the importance of taking their medication as
prescribed, taking pulse before daily dose, and reporting for periodic blood levels.
 Teach signs of impending heart failure—increasing edema, shortness of breath,
decreasing urine output, decreasing BP, increasing pulse—and tell patient to notify
health care provider immediately.
 See specific measures for MI (see page 394), cardiomyopathy (see page 410), and
valvular disease (see page 420).

6.Evaluation: Expected Outcomes

 CO greater than 4 L/minute; CI greater than 2.2, PCWP less than 18 mm Hg

 Respirations unlabored and regular; normal breath sounds throughout lung fields
 Normal sensorium; urine output adequate; skin warm and dry
 Verbalizes lessened anxiety and fear