NUR 111 (Nursing Care of Clients with Life –

Threatening Conditions, Acutely Ill/Multi-organ

Problems, High Acuity and Emergency
STUDENT ACTIVITY SHEET Situation)
BS NURSING / FOURTH YEAR
Session # 7

LESSON TITLE: Cardiogenic Shock

Materials: MS notebook, paper, pen, index card,
LEARNING TARGETS: and bond paper (short & long size)
At the end of the lesson, the student nurses will be to: References:

1. Define cardiogenic shock and classify according to its
causes;
2. Trace the pathophysiology of the disease;
3. Discuss its causes, clinical manifestations and
diagnostic findings;
4. Illustrate nursing management in the care of client with
cardiogenic shock; and.
5. Describe home care guidelines and documentation
guidelines.
Smeltzer S.C., & Bare B.G. (2010) Brunner and
Suddarth’s Textbook of Medical- Surgical Nursing.
Lippincott William & Wilkins
Sommer S., Johnson J. (2013) RN Adult Medical
Surgical Nursing. Assessment Technology
Institute, LLC.
https://www.nurseslab.com

LESSON PREVIEW/REVIEW (10 minutes)

Instruction: List the signs and symptoms associated to the following conditions.

Left-sided Right-sided
Heart Failure Heart Failure

MAIN LESSON (60 minutes)

CARDIOGENIC SHOCK

Cardiogenic shock is also sometimes called “pump failure”. Cardiogenic shock is a condition of diminished cardiac
output that severely impairs cardiac perfusion. It reflects severe left-sided heart failure.

Pathophysiology
This is what happens in cardiogenic shock:
1. Inability to contract. When the myocardium can’t contract sufficiently to maintain adequate cardiac
output, stroke volume decreases and the heart can’t eject an adequate volume of blood with each contraction.
2. Pulmonary congestion. The blood backs up behind the weakened left ventricle, increasing preload and causing
pulmonary congestion.
3. Compensation. In addition, to compensate for the drop in stroke volume, the heart rate increases in an attempt to
maintain cardiac output.
4. Diminished stroke volume. As a result of the diminished stroke volume, coronary artery perfusion and collateral
blood flow is decreased.
5. Increased workload. All of these mechanisms increase the heart’s workload and enhance left-sided heart failure.
6. End result. The result is myocardial hypoxia, further decreased cardiac output, and a triggering of compensatory
mechanisms to prevent decompensation and death.

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 1 of 8
Classification
The causes of cardiogenic shock are known as either coronary or non-coronary.
 Coronary. Coronary cardiogenic shock is more common than noncoronary cardiogenic shock and is seen most
often in patients with acute myocardial infarction.
 Noncoronary. Noncoronary cardiogenic shock is related to conditions that stress the myocardium as well as
conditions that result in an ineffective myocardial function.
Cardiogenic shock could be fatal if left untreated.
 Cardiogenic shock occurs as a serious complication in 5% to 10% of patients hospitalized with acute myocardial
infarction.
 Historically, mortality for cardiogenic shock had been 80% to 90%, but recent studies indicate that the rate has
dropped to 56% to 67% due to the advent of thrombolytics, improved interventional procedures, and better
therapies.
 Incidence of cardiogenic shock is more common in men than in women because of their higher incidence of
coronary artery disease.

Causes
Cardiogenic shock can result from any condition that causes significant left ventricular dysfunction with reduced cardiac
output.
 Myocardial infarction (MI). Regardless of the underlying cause, left ventricular dysfunction sets in motion a
series of compensatory mechanisms that attempt to increase cardiac output, but later on leads to deterioration.
 Myocardial ischemia. Compensatory mechanisms may initially stabilize the patient but later on would cause
deterioration with the rising demands of oxygen of the already compromised myocardium.
 End-stage cardiomyopathy. The inability of the heart to pump enough blood for the systems causes cardiogenic
shock.

Statistics and Incidences

 Cardiogenic shock could be fatal if left untreated.
 Cardiogenic shock occurs as a serious complication in 5% to 10% of patients hospitalized with acute myocardial
infarction.
 Historically, mortality for cardiogenic shock had been 80% to 90%, but recent studies indicate that the rate has
dropped to 56% to 67% due to the advent of thrombolytics, improved interventional procedures, and better
therapies.
 Incidence of cardiogenic shock is more common in men than in women because of their higher incidence of
coronary artery disease.

Clinical Manifestations
Cardiogenic shock produces symptoms of poor tissue perfusion.
 Clammy skin. The patient experiences cool, clammy skin as the blood could not circulate properly to the
peripheries.
 Decreased systolic blood pressure. The systolic blood pressure decreases to 30 mmHg below baseline.
 Tachycardia. Tachycardia occurs because the heart pumps faster than normal to compensate for the decreased
output all over the body.
 Rapid respirations. The patient experiences rapid, shallow respirations because there is not enough oxygen
circulating in the body.
 Oliguria. An output of less than 20ml/hour is indicative of oliguria.
 Mental confusion. Insufficient oxygenated blood in the brain could gradually cause mental confusion and
obtundation.
 Cyanosis. Cyanosis occurs because there is insufficient oxygenated blood that is being distributed to all body
systems.

Assessment and Diagnostic Findings

Diagnosis of cardiogenic shock may include the following diagnostic tests:
 Auscultation. Auscultation may detect gallop rhythm, faint heart sounds and, possibly, if the shock results from
rupture of the ventricular septum or papillary muscles, a holosystolic murmur.
 Pulmonary artery pressure (PAP).PAP monitoring may show increase in PAP, reflecting a rise in left ventricular
end-diastolic pressure and increased resistance to the afterload.
 Arterial pressure monitoring. Invasive arterial pressure monitoring may indicate hypotension due to impaired
ventricular ejection.

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 2 of 8
  ABG analysis. Arterial blood gas analysis may show metabolic acidosis and hypoxia.
 Electrocardiography. Electrocardiography may show possible evidence of acute MI, ischemia, or
ventricular aneurysm.
 Echocardiography. Echocardiography can determine left ventricular function and reveal valvular abnormalities.
 Enzyme levels. Enzyme levels such as lactic dehydrogenase, creatine kinase. Aspartate aminotransferase and
alanine aminotransferase may confirm MI.

Medical Management
The aim of treatment is to enhance cardiovascular status by:
 Oxygen. Oxygen is prescribed to minimize damage to muscles and organs.
 Angioplasty and stenting. A catheter is inserted into the blocked artery to open it up.
 Balloon pump. A balloon pump is inserted into the aorta to help blood flow and reduce workload of the heart.
 Pain control. In a patient that experiences chest pain, IV morphine is administered for pain relief.
 Hemodynamic monitoring. An arterial line is inserted to enable accurate and continuous monitoring of BP and
provides a port from which to obtain frequent arterial blood samples.
 Fluid therapy. Administration of fluids must be monitored closely to detect signs of fluid overload.

Pharmacologic Therapy
Drug therapy may include:
 IV dopamine. Dopamine, a vasopressor, increases cardiac output, blood pressure, and renal blood flow.
 IV dobutamine. Dobutamine is an inotropic agent that increase myocardial contractility.
 Norepinephrine. Norepinephrine is a more potent vasoconstrictor that is taken when necessary.
 IV nitroprusside. Nitroprusside is a vasodilator that may be used with a vasopressor to further improve cardiac
output by decreasing peripheral vascular resistance and reducing preload.

Surgical Management
When the drug therapy and medical procedures don’t work, then the last option is for surgical procedure.
 Intra-aortic balloon pump (IABP). The IABP is a mechanical-assist device that attempts to improve the coronary
artery perfusion and decrease cardiac workload through an inflatable balloon pump which is percutaneously or
surgically inserted through the femoral artery into the descending thoracic aorta.

Nursing Management
Cardiogenic shock needs rapid, accurate nursing management.

A. Nursing Assessment
The nurse should assess the following:
 Vital signs. Assess the patient’s vital signs, especially the blood pressure.
 Fluid overload. The ventricles of the heart cannot fully eject the volume of blood at systole, so fluid may
accumulate in the lungs.

B. Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses are:
 Decreased cardiac output related to changes in myocardial contractility/inotropic changes
 Impaired gas exchange related to changes in alveolar-capillary membrane.
 Excess fluid volume related to a decrease in renal organ perfusion, increased sodium and water, hydrostatic
pressure increase, or decrease plasma protein.
 Ineffective tissue perfusion related to reduction/cessation of blood flow.
 Acute pain related to ischemic tissues secondary to blockage or narrowing of coronary arteries.
 Activity intolerance related to imbalance between the oxygen supply and needs.

C. Nursing Care Planning & Goals

The major goals for the patient are:
 Prevent recurrence of cardiogenic shock.
 Monitor hemodynamic status.
 Administer medications and intravenous fluids.
 Maintain intra-aortic balloon counter pulsation.

D. Nursing Interventions
The appropriate nursing interventions for a patient with cardiogenic shock includes:

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 3 of 8
  Prevent recurrence. Identifying at-risk patients early, promoting adequate oxygenation of the heart muscle, and
decreasing cardiac workload can prevent cardiogenic shock.
 Hemodynamic status. Arterial lines and ECG monitoring equipment must be well maintained and functioning;
changes in hemodynamic, cardiac, and pulmonary status and laboratory values are documented and reported;
and adventitious breath sounds, changes in cardiac rhythm, and other abnormal physical assessment findings are
reported immediately.
 Fluids. IV infusions must be observed closely because tissue necrosis and sloughing may occur if vasopressor
medications infiltrate the tissues, and it is also necessary to monitor the intake and output.
 Intra-aortic balloon counter pulsation. The nurse makes ongoing timing adjustments of the balloon pump to
maximize its effectiveness by synchronizing it with the cardiac cycle.
 Enhance safety and comfort. Administering of medication to relieve chest pain, preventing infection at the
multiple arterial and venous line insertion sites, protecting the skin, and monitoring respiratory and renal functions
help in safeguarding and enhancing the comfort of the patient.
 Arterial blood gas. Monitor ABG values to measure oxygenation and detect acidosis from poor tissue perfusion.
 Positioning. If the patient is on the IABP, reposition him often and perform passive range of motion exercises to
prevent skin breakdown, but don’t flex the patient’s “ballooned” leg at the hip because this may displace
or fracture the catheter.

E. Evaluation
Expected outcomes include:
 Prevented recurrence of cardiogenic shock.
 Monitored hemodynamic status.
 Administered medications and intravenous fluids.
 Maintained intra-aortic balloon counter pulsation.

F. Discharge and Home Care Guidelines

Lifestyle changes must be made to avoid the recurrence of cardiogenic shock.
 Control hypertension. Exercise, manage stress, maintain a healthy weight, and limit salt and alcohol intake.
 Avoid smoking. The risk of stroke is the same for smokers and non -smokers’ years after you stop smoking
 Maintain a healthy weight. Losing those extra pounds would be helpful in lowering the cholesterol and blood
pressure.
 Diet. Eat less saturated fat and cholesterol to reduce heart disease.
 Exercise. Exercise daily to lower blood pressure, increase high-density lipoproteins, and improve the overall
health of the blood vessels and the heart.

G. Documentation Guidelines
The focus of documentation includes:
 Baseline and subsequent findings and individual hemodynamic parameters, heart and breath sounds, ECG
pattern, presence/strength of peripheral pulses, skin/tissue status, renal output, and mentation.
 Respiratory rate, character of breath sounds, frequency, amount, and appearance of secretions, presence of
cyanosis, laboratory findings, and mentation level.
 Conditions that may interfere with oxygen supply.
 Conditions contributing to the degree of fluid retention.
 I&O, fluid balance.
 Pulses and BP.
 Client’s description of response to pain.
 Acceptable level of pain.
 Specifics of pain inventory.
 Prior medication use.
 Plan of care.
 Teaching plan.
 Client’s responses to interventions, teaching, and actions performed.
 Status and disposition at discharge.
 Attainment or progress toward desired outcomes.

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 4 of 8
CHECK FOR UNDERSTANDING (25 minutes)
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 25 minutes for this activity:

Multiple Choice

1. A patient is being treated for cardiogenic shock. Which statement below best describes this condition? Select all that
apply:
A. “The patient will experience an increase in cardiac output due to an increase in preload and afterload.”
B. “A patient with this condition will experience decreased cardiac output and decreased tissue perfusion.”
C. “This condition occurs because the heart has an inadequate blood volume to pump.”
D. “Cardiogenic shock leads to pulmonary edema.”
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

2. Cardiac output is very important for determining if a patient is in cardiogenic shock. What is a normal cardiac output in
an adult?
A. 2-5 liters/minute
B. 1-3 liters/minute
C. 4-8 liters/minute
D. 8-10 liters/minute
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

3. Which patient below is at MOST risk for developing cardiogenic shock?

A. A 52-year-old male who is experiencing a severe allergic reaction from shellfish.
B. A 25-year-old female who has experienced an upper thoracic spinal cord injury.
C. A 72-year-old male who is post-op from a liver transplant.
D. A 49-year-old female who is experiencing an acute myocardial infarction.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

4. You’re caring for a patient with cardiogenic shock. Which finding below suggests the patient’s condition is worsening?
Select all that apply:
A. Blood pressure 95/68
B. Urinary output 20 mL/hr
C. Cardiac Index 3.2 L/min/m2
D. Pulmonary artery wedge pressure 30 mmHg
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

5. You’re precepting a new nurse. You ask the new nurse to list the purpose of why a patient with cardiogenic shock may
benefit from an intra-aortic balloon pump. What responses below indicate the new nurse understands the purpose of an
intra-aortic balloon pump? Select all that apply:
A. “This device increases the cardiac afterload, which will increase cardiac output.”
B. “This device will help increase blood flow to the coronary arteries.”
C. “The balloon pump will help remove extra fluid from the heart and lungs.”
D. “The balloon pump will help increase cardiac output.”
ANSWER: ________

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 5 of 8
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

6. A patient is receiving treatment for an acute myocardial infarction. The nurse is closely monitoring the patient for signs
and symptoms associated with cardiogenic shock. Which value below is associated with cardiogenic shock?
A. Cardiac index 1.5 L/min/m2
B. Pulmonary capillary wedge pressure (PCWP) 10 mmHg
C. Central venous pressure (CVP) 4 mmHg
D. Troponin <0.01 ng/mL
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

7. A patient who has cardiogenic shock is experiencing labored breathing and low oxygen levels. A STAT chest x-ray is
ordered. The x-ray results show pulmonary edema. The physician orders Furosemide IV. What finding would require
immediate nursing action?
A. Blood pressure 98/54
B. Urinary output 45 mL/hr
C. Potassium 1.8 mEq/L
D. Heart rate 110 bpm
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

8. They physician orders a Dobutamine IV drip on a patient in cardiogenic shock. After starting the IV drip, the nurse
would make it priority to monitor for?
A. Rebound hypertension
B. Ringing in the ears
C. Worsening hypotension
D. severe headache
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

9. Which medications below are used in cardiogenic shock that provide a positive inotropic effect on the heart? Select all
that apply:
A. Nitroglycerin
B. Sodium Nitroprussidde
C. Dobutamine
D. Norepinephrine
E. Dopamine
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

10. A patient with cardiogenic shock has an intra-aortic balloon pump. As the nurse you know that during ________ the
balloon deflates and during _____ the balloon inflates in a section of the aorta.
A. systole, diastole
B. diastole, systole
C. inspiration, expiration
D. expiration, inspiration
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 6 of 8
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

10. ANSWER: ________

RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 7 of 8
LESSON WRAP-UP (25 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy - Think-Pair-Share

Instruction: Find a partner and together develop a home care management plan/ discharge plan for client with
cardiogenic shock. You will be given 20 minutes to finish the activity.

AL Activity: CAT: 3-2-1

Instructions:

1. As an exit ticket at the end of the class period

2. Record three things you learned from the lesson.
3. Next, two things that you found interesting and that you’d like to learn more about.
4. Then, record one question you still have about the lesson.

Three things you learned:

1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________

Two things that you’d like to learn more about:

1. __________________________________________________________________________________
2. __________________________________________________________________________________

One question you still have:

1. __________________________________________________________________________________

(For Related Learning Experience, please refer to your clinical instructor.)

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 8 of 8