Cardiogenic Shock NCLEX Review
is the amount of blood the heart
What is cardiogenic shock? It’s where the heart
can NOT pump enough blood to meet the perfusion
needs of the body.
Therefore, the heart does not pump enough blood
throughout the body, which will decrease cardiac
output and this leads to a decrease in tissue
perfusion and oxygen supply to the organs/tissue’s
cells.
Note: In cardiogenic shock, there is NOT an issue
with a loss of blood volume like in some of the other
types of shock. Blood volume is normal. However,
because the heart has experienced a decrease in its
ability to function properly, that blood volume starts
to back up and leads to congestion in the lungs and
the right side of the body (keep this in mind for
when we review the signs and symptoms).
Let’s break down the heart’s role:
The heart is the PUMP of the body. It takes blood
to the right side of the heart that has been used and
depleted of oxygen by the cells of the body and
pumps it to the lungs. The lungs oxygenate and
remove carbon dioxide from the blood and sends it
back to the heart via its left side.
The left side is very strong, especially the left
ventricle, which is the main pumping chamber of the
heart. The left side shoots the fresh oxygenated
blood into the aorta. The aorta branches off into
many arteries that go into this complex network of
vessels to feed the organs oxygenated blood.
Therefore, the heart is the main center piece in the
body that plays a role in tissue perfusion, and
everything in the body depends on the heart for its
survival. If the heart can’t pump blood efficiently,
the organs don’t receive fresh oxygenated blood and
the cells that make up that organ start to die.
Therefore in a nutshell, when the heart can’t
pump, cardiac output falls, which decreases
tissue perfusion and the cells that make up our
organs don’t receive enough oxygen to work. They
start to panic and eventually die.
When cardiac output falls (hence the blood pressure
drops), the patient begins to enter the stages of
shock (we talked about the stages of shock in the
previous lecture: initial, compensatory,
progressive, and refractory).
Cardiac Output and Cardiogenic Shock
First, let’s talk about cardiac output because it’s a
very important term you should know when taking
care of a patient with cardiogenic shock:
Cardiac output 
pumps per minute. The heart’s cardiac output should
be anywhere from 4-8 liters of blood per minute.
Cardiac output is determined by the person’s heart
rate times the stroke volume.
Stroke volume is the amount of blood pumped
from the left ventricle each beat (50-100 ml). Stroke
volume is determined by the preload, afterload,
and contractility of the heart.
Preload is the amount the ventricle stretches at the
end of diastole (hence it’s the amount the ventricles
stretch once their filled with blood….so it’s the end-
diastolic volume).  Remember diastole is the
relaxation/filling phase of the heart.
Afterload is the pressure the ventricle must pump
against to squeeze blood out. Therefore, it’s the
force the heart has to pump against to get blood out
of the ventricle.
Contractility is how well the muscle cells are
contracting. Therefore, it’s how well the heart is
contracting to pump blood.
If the stroke volume falls (meaning the heart muscle
is NOT pumping blood very well), the cardiac output
decreases and this leads to a fall in tissue perfusion.
So, in other words, cardiac output tells us how well
the heart is pumping and perfusing the cells that
make up our organs.
When we talk about treatment for cardiogenic shock
it will include medications that will affect preload,
afterload, and contractility via drugs like
vasopressors, inotropes, vasodilators, and diuretics.
Examples:
 if the afterload is decreased (which is the
resistance the heart must pump against to
get blood out of the heart if you decrease
this, it makes it easier for the heart to pump
blood forward) the stroke volume will
increase hence delivering a higher cardiac
output vasodilators can achieve this.
 if contractility is increased (which is
how strong the muscle cell contracts) it
will increase stroke volume and cardiac
output positive inotropic medications
can achieve this.
 if preload is increased (which is the
amount the ventricle stretches at the
end of diastole) the stroke volume will
increase hence delivering a higher
cardiac output vasopressors can
achieve this by causing
vasoconstriction, which will increase
venous return to the heart.
Another term you may see, especially when talking
about cardiogenic shock, is Cardiac Index.
This is a more specific cardiac output measurement
based on the patient’s body size. It’s calculated by
taking the cardiac output and dividing it by the
patient’s body surface area.
Patients with cardiogenic shock will have a CI
(cardiac index) less than 2.2 L/min/m2.
Normal CI is: 2.5-4 L/min/m2
Causes of Cardiogenic Shock
What can cause the heart’s cardiac output to
fall (hence cardiogenic shock)?
Issues that cause the heart to have problems:
 contracting (systolic dysfunction) the heart
can’t successfully pump blood out of the
heart and to the body
 filling (diastole dysfunction) the heart’s
chambers don’t fill properly so blood really
can’t be pumped to perfuse the body
Examples:
 ****Main cause: Acute myocardial
infarction (contracting issue): this is
known as a heart attack. It occurs due to a
blockage in the coronary arteries. The
coronary arteries supply the cells of the heart
muscle with oxygen. When blood flow is
dramatically decreased or blocked completely
to the cells that make up the heart muscle,
they start to die. When majority of the blood
flow to the left coronary is diminished, the
muscle cells that make up the left ventricle
die. Remember the left ventricle is the main
pumping chamber of the heart. It pumps the
blood to the aorta which then goes to the
body. If a patient has an acute myocardial
infarction that affects the left ventricle, the
patient is at high risk for developing
cardiogenic shock.
 Why? When the heart cells die, the heart
doesn’t contract (pump) like it should,
especially the left ventricle. Preload,
afterload, contractility are all going to
be affected along with the heart
rate.  Cardiac output falls (can’t pump much
blood per minute) and tissue perfusion is
decreased to the body’s cells.
 Pericardial tamponade (filling
issue): too much fluid is around the heart,
so it can’t fill properly.
Other causes: dysrhythmias,
myocarditis, endocarditis, pulmonary edema,
structure issues with valves and/or septal walls etc.
Quick Patho on what happens during
cardiogenic shock  volume so cardiac output can be increased.
Cause (ex: acute myocardial infarction) -> major cell
damage to the heart muscle -> can’t pump
efficiently ability to pump blood out of the heart and
to the body has decreased -> decreases stroke
volume -> decreased cardiac output -> decreases
perfusion to the body’s cells that make up our
organs and tissues -> cell injury (signs and
symptoms of body systems struggling due to low
oxygen)
Signs and Symptoms of Cardiogenic Shock
When trying to recall these signs and symptoms,
think about what happens in the body due to
decreased cardiac output and when blood starts to
back flow into the lungs and the right side of the
heart.
Let’s break down the signs and symptoms by body
systems:
Heart: it’s weak and not pumping blood forward or
filling efficiently this leads to:
 Back flow of blood from the left side to
the lungs (pulmonary
congestion,  crackles, dyspnea,
increased respiratory rate, low oxygen,
increased heart rate)
 As it progresses, blood will back flow
from the lungs to the right side of the
heart (neck veins become distended
due to an increase in venous pressure
and there will be a high CVP central
venous pressure)
 Chest pain (decrease perfusion to heart
muscle via the coronary arteries)
 Hypotension: Systolic blood pressure less
than 90 mmHg or 40 mmHg from baseline
for at least 30 minutes
 Weak peripheral pulses
 If on hemodynamic monitoring may have:
 Decreased cardiac index <2.2 L/min/m2
 Increased pulmonary capillary wedge
pressure (PCWP) >18 mmHg
 Increased central venous pressure
Brain: cells are not being perfused due to low
cardiac output and the build-up of waste in the body
(liver and kidneys are failing to filter out toxic
substances) leads to confusion, agitation,
restlessness.
Kidneys: decreased blood flow to the kidneys
activates the renin-angiotensin system. This leads to
the release of angiotensin II, which leads to the
release of aldosterone and ADH (antidiuretic
hormone). These substances will cause the kidneys
to keep sodium and water (aldosterone) and cause
the body to retain water (ADH) leads to oliguria <30
mL/hr urinary output
 WHY? These substances are naturally
released by the body to help increase blood
 Other signs and symptoms will be associated
with renal failure like an increased BUN and
creatinine.
Skin: decreased perfusion to the skin leads to
decreased capillary refill, cool, pale, and clammy skin
Nursing Interventions for Cardiogenic Shock
To understand the nursing interventions, we need to
know the goals of medical treatment for a patient
with cardiogenic shock. Goals include:
 reperfusion to the heart muscle if there is a
decreased blood flow to the heart muscle via
the coronary arteries. The can be performed
via a heart catheterization, and if a blockage
is found, a stent can be placed.
 increase cardiac output via cardiac
medications (most meds are titrated and the
patient is on hemodynamic monitoring to
assess certain pressures in the heart)
 decrease fluid overload, if present (via
diuretics)
 maintain oxygen status due to pulmonary
edema (will need mechanical ventilation)
Nurse’s Role: Hemodynamic monitoring (more
about this below), maintain mechanical ventilation
(will need to help with respiratory failure), central
line placement for medication, monitoring, assessing
for signs of adequate tissue perfusion: mental
status, blood pressure, heart rate, rhythm, urine
output, skin color and capillary refill, lung sounds
etc.
Monitoring labs: high cardiac markers ex: elevated
troponin (this substance is released if there is injury
to heart cells), increased BNP (this substance is
released by the cells that make up the ventricles
when they stretch due to high blood volume),
pulmonary edema on chest x-ray, echocardiogram
(show a low ejection fraction), acid-base level that
demonstrate acidosis serum lactate >4 mmol/L (cells
will switch from aerobic to anaerobic metabolism
which will produce lactic acid), drop in blood ph
<7.35
Hemodynamic monitoring:
Pulmonary artery wedge pressure/pulmonary
capillary wedge pressure (increased in
cardiogenic shock): a pulmonary artery catheter
(Swan-Ganz catheter) is inserted through the right
side of the heart via a vessel and the catheter is
wedged in the pulmonary arterial branch and a
balloon is temporarily inflated to measure left atrial
filling pressure.
 Normal 4-12 mmHg
 >18 mmHg in cardiogenic shock blood is
backing up in the heart and lungs (hence not
being pumped out and creating a high
pressure in the left atrium)
Central venous pressure (CVP): catheter used to
measure the pressure in the right atrium and
superior vena cava.
 INCREASED in cardiogenic
shock (Normal CVP is 2 to 6 mmHg or 8-12
mmHg depending on source).
 WHY? The back flow of blood to the right
side of the heart (right atrium into venous
circulation) leads to venous congestion,
which increases the central venous pressure.
Medications: a combination of medications can be
given and medications vary depending on the cause
of the cardiogenic shock and the patient’s response.
Diuretics: cardiogenic shock is one of the two types
of shock that doesn’t have a decrease in blood
volume (the other is neurogenic shock).
 Patients with cardiogenic shock have a
backup of fluid in the lungs from an injured
heart that is failing to pump blood forward.
 Diuretics (ex: furosemide watch
potassium level “hypokalemia“ normal
level is 3.5-5 mEq/L) will help remove
extra fluid volume via the kidneys. This will
decrease the preload (amount ventricles
stretch at the end of diastole), which will
help the relieve the workload of the heart.
However, watch the fluid status of the
patient, renal function, and for worsening
hypotension.
Vasopressors: causes constriction of vessels and
increases preload (venous return) and cardiac
output
 Norepinephrine (vasoconstrictor) sometimes
used over dopamine because it doesn’t cause
tachydysrhythmias: it increases tissue
perfusion by increasing blood pressure
Vasopressors that create a positive inotropic
effect: increases the strength of the heart’s
contraction (increases contractility) and stroke
volume
 Dobutamine (increases contractility and
cardiac output BUT can
cause vasodilation due to the way it acts
on receptors and may make hypotension
WORSE. If this occurs that patient may be
started on norepinephrine or dopamine.
 Dopamine (increase contractility, causes
vasoconstriction: increases blood pressure
and MAP (want >60 mmHg), but watch out
for tachydysrhythmias)
Vasodilators: decreases preload and afterload:
increases stroke volume because it decreases the
afterload, so it’s easier for the heart to pump blood
forward so cardiac output increases. The workload
on the heart decreases by dilating the coronary
arteries causes hypotension and may not be used if
the patient is severely hypotensive (monitor blood
pressure very closely). Ex: Nitroglycerin or
Sodium Nitroprusside
IV Fluids: Normal saline (if even used) is used with
extreme caution due to pulmonary edema that may
be present. A fluid challenge is majorly used for the
other types of shock when blood volume is the
issue…remember in cardiogenic shock blood volume
is not the issue.
Intra-aortic balloon pump
It’s a device placed to help improve coronary
artery blood flow and increase cardiac output.
How? A catheter is inserted through a vessel (ex:
femoral artery) up through a section of the aorta. A
balloon attached to the catheter will inflate and
deflate during systole (contraction) and diastole
(relaxation).
When the balloon deflates during systole. it creates
a suction-like pressure that will draw blood out of
the weak heart and into the coronary arteries and
systemic circulation (hence increasing cardiac output
and blood supply to the heart muscle).
When the balloon inflates during diastole. it will
create pressure that will push blood into the
coronary arteries (hence further increasing blood
supply to the heart muscle).
Cardiogenic Shock NCLEX Questions
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.”
The answers are: B and D. Cardiogenic shock occurs
when the heart can NOT pump enough blood to
meet the perfusion needs of the body. The cardiac
output will be DECREASED, which will DECREASE
tissue perfusion and cause cell injury to
organs/tissues. In this condition, the heart is WEAK
and can’t pump blood out of the heart. This can be
due to either a systolic (contraction) or diastolic
(filling) issue along with a structural or dysrhythmia
issue. In cardiogenic shock, there is NOT an issue
with blood volume, but there is a problem with the
heart itself.
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
The answer is C. Cardiac output is the amount of
blood the heart pumps per minute. The heart’s
cardiac output should be anywhere from 4-8 liters of
blood per minute.
3. ________________ is the amount the ventricle
stretches at the end of diastole.
A. Preload
B. Afterload
C. Stroke Volume
D. Contractility
The answer is A. Preload is the amount the ventricle
stretches at the end of diastole (hence it’s the
amount the ventricles stretches once it’s filled with
blood and right before the contraction of the
ventricle ….so it’s the end-diastolic volume).
4. Cardiac output is equal to the heart rate
multiplied by the stroke volume. Treatment for
cardiogenic shock includes medications that increase
cardiac output. One of the factors that help
determine cardiac output is stroke volume. Select all
the factors that determine stroke volume?
A. Cardiac Index
B. Preload
C. Pulmonary capillary wedge pressure
D. Afterload
E. Heart rate
F. Contractility
The answers are B, D, and F. Cardiac output is
determined by the person’s heart rate times the
stroke volume. Stroke volume is the amount of blood
pumped from the left ventricle with each BEAT (50-
100 ml). It’s determined by the preload, afterload,
and contractility of the heart. These factors in a
patient with cardiogenic shock can be manipulated
with medications to increase the cardiac output.
5. _____________ is the force the heart has to
pump against to get blood out of the ventricle.
A. Cardiac output
B. Cardiac index
C. Preload
D. Afterload
The answer is D. Afterload is the pressure the
ventricle must pump against to squeeze blood out.
In other words, it’s the force the heart has to pump
against to get blood out of the ventricle.
6. True or False: If a patient with cardiogenic shock
is given a medication that will decrease cardiac
afterload, it will decrease stroke volume.
The answer is FALSE. If a patient with cardiogenic
shock is given a medication that will decrease
cardiac afterload, it will INCREASE (not decrease)
stroke volume. HOW? Remember afterload is the
resistance the ventricle must pump against to get
blood out of the heart. If we DECREASE the
resistance the heart must pump against (make it
easier for the heart squeeze blood out of the
ventricle), it will increase how much blood it will
pump out, hence increase the stroke volume.
7. 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.
The answer is D. An acute MI (heart attack) is the
main cause of cardiogenic shock. It happens
because a coronary artery has become blocked.
Coronary arteries supply the heart muscle’s cells
with oxygenated blood. If they don’t receive this
oxygenated blood they will die, which causes the
heart muscle to quit working (hence pumping
efficiently). When the heart muscle fails to pump
efficiently, cardiac output fails and cardiogenic shock
occur.
8. 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
The answer is B and D. When answering this
question look for values that are abnormal and that
point to worsening tissue perfusion (urinary output
should be 30 mL/hr or greater….if it’s lower than this
it show the kidneys are not being perfused) and
worsening cardiac output (the blood pressure and
cardiac index are within normal limits BUT
pulmonary artery wedge pressure is NOT). A
pulmonary artery wedge pressure (also called
pulmonary capillary wedge pressure) is the pressure
reading of the filling pressure in the left atrium. A
normal PAWP is 4-12 mmHg and if it’s >18 mmHg
this indicates cardiogenic shock. If it reads high, that
means there is back-flowing of blood into the heart
and lungs (hence the left ventricle is failing to pump
efficiently and increasing the pressure in the left
atrium).
9. A patient with cardiogenic shock has a blood
pressure of 70/38. In addition, the patient is
experiencing dyspnea with a respiratory rate of 32
breaths per minute and has an oxygen saturation of
82% on room air. On auscultation, you note crackles
throughout the lung fields. You notify the physician.
What order below would you ask for an order
clarification?
A. Dopamine IV stat
B. Normal saline IV bolus stat
C. Furosemide IV stat
D. Place patient on CPAP (continuous positive airway
pressure)
The answer is B. This patient with cardiogenic shock
is experiencing a decrease in cardiac output (hence
the blood pressure), so an order for Dopamine can
help provide a positive inotropic effect (increase the
contractility of the heart which will increase stroke
volume and cardiac output). The patient is also
experiencing pulmonary congestion due to the
cardiogenic shock. The heart is failing to pump blood
forward, so it is backing up in the lungs. This is
leading to an increased respiratory rate, dyspnea,
and low oxygen saturation. The order for
Furosemide (which is a diuretic) will help remove the
extra fluid volume from the lungs and the CPAP
(continuous positive airway pressure) will help with
oxygenation. The nurse would question the order for
a normal saline IV bolus. This bolus would add more
fluid to the lungs and further congest the fluids.
10. You’re assessing your patient with cardiogenic
shock, what signs and symptoms do you expect to
find in this condition? Select all that apply:
A. Warm, flushed skin
B. Prolonged capillary refill
C. Urinary output >30 mL/hr
D. Systolic blood pressure <90 mmHg
E. Crackles in lung fields
F. Dyspnea
D. Decreased BUN and creatinine
G. Strong peripheral pulses
H. Chest pain
The answers are B, D, E, F, and H. Signs and
symptoms of cardiogenic shock will be related to
LOW cardiac output and decreased perfusion to
organs/tissues. Capillary refill will be prolonged >2
seconds, urinary output will be <30 mL/hr, systolic
blood pressure will be <90 mmHg, pulmonary
edema will present with fluid in the lungs (hence
crackles in the lungs), dyspnea, and chest pain (due
to decreased blood flow to the heart muscle).
11. 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
The answer is A. A patient who has experienced an
acute myocardial infarction is at risk for cardiogenic
shock. A normal cardiac index should be 2.5-4
L/min/m2. Cardiac index is the specific cardiac
output based on the patient’s size. Any number less
than 2.2 L/min/m2 can be associated with
cardiogenic shock. All the other values are within
normal limits. PCWP would be >18 mmHg in
cardiogenic shock, and CVP would be high.
12. 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 16. You’re precepting a new nurse. You ask the new
B. Urinary output 45 mL/hr nurse to list the purpose of why a patient with
C. Potassium 1.8 mEq/L cardiogenic shock may benefit from an intra-aortic
D. Heart rate 110 bpm balloon pump. What responses below indicate the
The answer is C. Furosemide (Lasix) is a diuretic new nurse understands the purpose of an intra-
which wastes potassium. The nurse would want to aortic balloon pump? Select all that apply:
ensure the potassium level is normal (3.5 to 5 A. “This device increases the cardiac afterload,
mEq/L) before administering IV Furosemide. The which will increase cardiac output.”
nurse would need to notify the physician of the B. “This device will help increase blood flow to the
potassium level so supplementation can be provided. coronary arteries.”
13. They physician orders a Dobutamine IV drip on a C. “The balloon pump will help remove extra fluid
patient in cardiogenic shock. After starting the IV from the heart and lungs.”
drip, the nurse would make it priority to monitor for? D. “The balloon pump will help increase cardiac
A. Rebound hypertension output.”
B. Ringing in the ears The answers are B and D. An intra-aortic balloon
C. Worsening hypotension pump increases coronary artery blood flow and
D. severe headache cardiac output.
The answer is C. Dobutamine increases contractility
and cardiac output, BUT causes vasodilation due to
the way it acts on receptors and this may make
hypotension WORSE. The patient may be started on
norepinephrine or dopamine if worsening of
hypotension occurs.
14. 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
The answers are C and E. Dobutamine and
Dopamine are vasopressors that have a POSITIVE
inotropic effect on the heart. This means these
medications increase the strength of the heart’s
contractions (increases contractility), which
increases stroke volume.
15. 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
The answer is A. An intra-aortic balloon pump is a
balloon attached to the catheter inside a section of
the aorta. It will inflate and deflate during systole
(contraction) and diastole (relaxation). When the
balloon deflates during systole it creates a suction-
like pressure that will draw blood out of the weak
heart and into the coronary arteries and systemic
circulation (hence increasing cardiac output and
blood supply to the heart muscle). When the balloon
inflates during diastole it will create pressure that
will push blood into the coronary arteries (hence
further increasing blood supply to the heart muscle).