CASE STUDY OF ATHEROSCLEROSIS

1. Risk factors of Atherosclerosis

• High cholesterol levels of 220 mEq/L – normal cholesterol level is less than
170mg/dL
• Lifestyle – lack of exercise and eating unhealthy foods
• Smoking - this can damage and tighten blood vessels, raise cholesterol
levels, and raise blood pressure - smoking also doesn't allow enough
oxygen to reach the body's tissues.
• Alcohol - heavy drinking can damage the heart muscle and worsen other
risk factors for atherosclerosis - men should have no more than two drinks
containing alcohol a day
• Overweight (BMI of 27.3) – normal BMI is 18.5 – 24.9; for his weight and
height it is considered unhealthy
• Family History – Patient C has a family history of early CHD in men and
diabetes in women
• Age – as age increases the risk for atherosclerosis also increases
• Gender – atherosclerosis is more common in men than women
• Stress - research shows that the most commonly reported "trigger" for a
heart attack is an emotionally upsetting event-particularly one involving
anger.

2. Etiology, Pathology, Clinical Manifestation and Therapeutic Treatment of

Carcinogenic Shock

a. Etiology
Cardiogenic shock is a dangerous condition that occurs when the heart is
unable to pump adequate blood and oxygen into the brain, kidneys and other
vital organs. Cardiogenic shock is deemed to be a medical emergency and
should be promptly treated. A heart attack is the most common cause of
cardiogenic shock. Other health issues that may contribute to cardiogenic
shock include heart conditions such as heart failure; chest injuries; side effects
of medicine; and conditions that prohibit blood from free circulating through the
heart, such as a blood clot in the lungs or arteries.

b. Pathology
Cardiogenic shock due to cardiac dysfunction is characterized by
inadequate tissue perfusion and is often caused by acute myocardial infarction.
Cardiogenic shock pathophysiology includes a circular spiral circle: ischemia
triggers myocardial dysfunction which in turn exacerbates myocardial ischemia.
Myocardial stunning and/or hibernating myocardium can boost myocardial
dysfunction, worsening the cardiogenic shock as a result. Low perfusion
pressures lead to multiorgan dysfunction with global ischemia. Ischemia and
 reperfusion can lead to systemic inflammation or sepsis within the first few days
due to the translocation of bacteria or bacterial intestinal toxins, which can lead
to increased mortality.

c. Clinical Manifestation
• Low blood pressure – the systolic blood pressure decreases to 30
mmHg below baseline.
• Weak, irregular pulse – tachycardia occurs because the heart pumps
faster than normal to compensate for the decreased output all over the
body.
• Breathing problems – the patient experiences rapid, shallow respirations
because there is not enough oxygen circulating in the body.
• Bulging of large veins on the neck
• Clammy skin – the blood could not circulate properly to the peripheries.
• Cold hands and feet
• Loss of consciousness
• Swelling of feet
• Oliguria or anuria – an output of less than 20ml/hour is indicative of
oliguria or no urine output at all
• Cyanosis – cyanosis occurs because there is insufficient oxygenated
blood that is being distributed to all body systems.

d. Therapeutic Treatment
Cardiogenic shock is life-threatening and requires immediate diagnosis and
identification of the cause and emergency attention for emergencies.
Treatments include medications, cardiac operations and surgical instruments
to help or repair the body's blood supply and avoid injury to the tissue.

Medicine can help improve blood supply and guard against damage to
organs. Any medications target the root cause of the cardiogenic reaction,
typically a heart attack. These medications include antiarrhythmic medications
to restore normal heartbeat; blood thinners or antiplatelet drugs to remove
blood clots and suppress platelets that can obstruct the heart's coronary
arteries and vasopressors and inotropes, such as norepinephrine and
dobutamine, to increase blood pressure and blood flow.

To avoid organ injury, the following surgical operations can be performed

instantly to restore blood supply throughout the heart and across the body.
Examples are percutaneous cardiac intervention (PCI) to open coronary
arteries that are narrowed or blocked by the buildup of plaque. A small mesh
tube called a stent may be implanted after PCI to prevent an artery from
narrowing again and percutaneous cardiac intervention (PCI) to free up
narrowed or blocked coronary arteries through plaque accumulation and
 coronary bypass transplantation (CABG) to enhance blood supply to the bone.
Typically, this treatment is performed as soon as possible after a cardiogenic
shock diagnosis is made.

A medical device may be required to assist, restore, or preserve blood

supply, and may avoid cardiogenic shock injury to the lungs. Often portable
devices assist patients waiting for surgery to install a permanent unit or for a
heart transplant. This includes extracorporeal membrane oxygenation (ECMO)
which circulates the blood and supplies oxygen to the organs of the body
through a cardiac machine outside the body; an intra-aortic balloon pump
(IABP) is no longer recommended for use alone in cardiogenic shocks but can
enhance survival when used in combination with ECMO. An IABP can also be
used primarily by patients who suffer from cardiogenic shock as a result of heart
failure before another treatment is available; and lastly a percutaneous
circulatory assisting devices (PCADs), and ventricular assisting devices
(VADs), can help sustain the heart while it heals, or while waiting for a heart
transplant.

Additional emergency treatments may include: continuous kidney dialysis

to filter waste out of the blood if the kidneys have been damaged, fluids inserted
into one of your blood vessels through an intravenous ( IV ) line to maintain
normal blood volumes, mechanical breathing support, such as a ventilator to
protect the airways and provide extra oxygen and oxygen therapy so that more
oxygen reaches the lungs, the heart, and the rest of the body.

3. Use of Dobutamine, Dopamine and Norepinephrine

Drug Name Drug Class Indication Rationale

Dobutamine Synthetic, Increase cardiac Commonly used in
Opioids, Opioid output in short-term cardiogenic shock.
Analgesics. treatment of cardiac Dobutamine is
decompensation used in the
caused by treatment of
decreased cardiac
contractility, such as decompensation
during refractory; due to depressed
heart failure; contractility.
adjunctive therapy
in cardiac surgery.
Dopamine Intropin Adjunct to standard Second line agent
measures to in most forms of
improve blood shock. Dopamine
pressure and stimulates beta-1
cardiac output. adrenergic
 Urine output in receptors, resulting
treatment of shock in increased
unresponsiveness cardiac output and
to fluid replacement.stimulates
dopamine
receptors, resulting
in vasodilatation.
Norepinephrine Vasopressor Produces Most common first
vasoconstriction and line agent in
myocardial shock.
stimulation, which Norepinephrine
may be required stimulates beta1-
after adequate fluid and alpha-
replacement in the adrenergic
treatment of severe receptors, resulting
hypotension and in increased
shock. cardiac muscle
contractility, heart
rate, and
vasoconstriction.

4. Nursing Outcomes

Expected and desired outcomes include prevented recurrence of

cardiogenic shock, monitored hemodynamic status, administered medications
and intravenous fluids, maintained intra-aortic balloon counter pulsation.

5. Nursing Interventions

Nursing Interventions Rationale

Assess the client’s respiratory rate,
rhythm, and depth.
Assess client’s heart rate and blood
pressure.
Assess for any signs of changes in
the level of consciousness.
Assess for cyanosis or pallor by
examining the skin, nail beds, and
mucous membranes.
During the early stages of shock, the
client’s respiratory rate will be
increased due to hypercapnia and
hypoxia. Once the shock progresses,
the respirations become shallow, and
the client will begin to hypoventilate.
As shock progresses, the client’s
blood pressure and heart rate will
decrease and dysrhythmias may
occur.
Headache, restlessness are early
signs of hypoxia.
Cool, pale skin may be secondary to a
compensatory vasoconstrictive
response to hypoxemia. Peripheral

Assess fluid balance and weight gain.
Assess urine output.
Monitor oxygen saturation using pulse
oximetry.
Monitor arterial blood gasses.
Administer IV fluids for clients with a
decreased preload.
Administer oxygen as prescribed.
Administer medications as prescribed
tissues become cyanotic due to
impaired oxygenation and perfusion.
Fluid and sodium retention occur due
to the compromised regulatory
mechanisms. Body weight is a good
indicator of fluid and sodium retention.
The renal system compensates for
low BP by retaining water. Oliguria is
a classic sign of inadequate renal
perfusion from reduced cardiac
output.
Pulse oximetry is used in measuring
oxygenation concentration. The
normal oxygen saturation should be
maintained at 90% or higher.
Increasing Pac02 and decreasing
Pa02 are signs of hypoxemia and
respiratory acidosis.
Optimal fluid status ensures effective
ventricular filling pressure. Too little
fluid reduces circulating blood volume
and ventricular filling pressures; too
much fluid can cause pulmonary
edema in a failing heart.
Oxygen may be required to maintain
oxygen saturation above 90% or as
indicated by order or protocol.
Medication therapy is more effective
when initiated early. The goal is to
maintain systolic BP greater than 90-
or 100-mm Hg.

6. Nursing Interventions for Discharge Against Medical Advice

Even after complete and thorough explanation is done as to why he (Patient

C) is not advised to go home and even medical and nursing interventions are
needed for him to complete the treatment for cardiogenic shock and prevent
atherosclerosis but still the patient insist in going home without doctor’s orders, the
nurses and other health care provides involved should make sure to get and
informed consent from the patient informing the doctor that he insist on going home
and it should be documented on his chart. As part of the patients’ right, the hospital
and health care providers cannot coerce patient to undergo treatment or cannot
restrain patients inside the hospital for treatment because patient has the right to
refuse treatment.