Prepared by

Demonstrator at faculty of nursing MTI university

02 01064423095

02 01144127776

Mustafaabdalla31@gmail.com
Cardiogenic shock
 is a condition caused by the inability of the heart to pump blood sufficiently to
meet the metabolic needs of the body due to the impaired contractility of the
heart. Clients usually manifest signs of low cardiac output, with adequate
intravascular volume.
 It is usually associated with myocardial infarction (MI), cardiomyopathies,
dysrhythmias, valvular stenosis, massive pulmonary embolism, cardiac
surgery, or cardiac tamponade. It is a self-perpetuating condition because
coronary blood flow to the myocardium is compromised, causing further
ischemia and ventricular dysfunction

Nursing Care Plans

The nursing care plan in clients with cardiogenic shock involves
 careful assess the client
 observe cardiac rhythm
 monitor hemodynamic parameters
 monitor fluid status
 adjust medications and therapies based on the assessment data

.Here are five (5) nursing care plans (NCP) for cardiogenic shock:
1) Impaired Gas Exchange
2) Decreased Cardiac Output
3) Ineffective Tissue Perfusion
4) Excess Fluid Volume
5) Anxiety
 1) Impaired Gas Exchange
Impaired Gas Exchange:Excess or deficit in oxygenation and/or carbon dioxide
elimination at the alveolar-capillary membrane.

May be related to

 Changes in the alveolar-capillary membrane.

 Impaired ventilation-perfusion.

Possibly evidenced by

 Abnormal arterial blood gasses (ABGs).

 Abnormal respiratory rate, depth, and rhythm.
 Changes in the level of consciousness.
 Crackles.
 Cyanosis.
 Headache.
 Hypercapnia.
 Hypoxia.
 Tachycardia.

Desired Outcomes

 Client will maintain optimal gas exchange, as evidenced by ABGs within

the normal range, oxygen saturation of 90% or greater, alert responsive
mentation or no further reduction in the level of consciousness, relaxed
breathing, and baseline HR for the client.

Nursing interventions

Nursing Interventions Rationale

During the early stages of shock, the client’s

Assess the client’s respiratory
rate, rhythm, and depth.
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. Respiratory failure develops
as the client experiences
respiratory muscle fatigue and decreased lung
compliance.
Assess client’s heart rate As shock progresses, the client’s blood pressure and
and blood pressure. heart rate will decrease and dysrhythmias may occur.

Assess for any signs of

changes in the level of Headache, restlessness are early signs of hypoxia.
consciousness.

Auscultate the lung for areas

Moist crackles are caused by increased pulmonary
of decreased ventilation and
capillary permeability and increased intra-alveolar
the presence of adventitious
edema.
sounds.

Assess for cyanosis or pallor Cool, pale skin may be secondary to a compensatory
by examining the vasoconstrictive response to hypoxemia. Peripheral
skin, nail beds, and mucous tissues become cyanotic due to impaired oxygenation
membranes. and perfusion.

Pulse oximetry is used in measuring oxygenation

Monitor oxygen saturation
concentration. The normal oxygen saturation should
using pulse oximetry.
be maintained at 90% or higher.

Increasing Pac02 and decreasing Pa02 are signs of

hypoxemia and respiratory acidosis. As the client’s
Monitor arterial blood gasses.
condition begins to fail, the respiratory rate will
decrease and Pac02 will continue to increase.

Assist the client when

Suction removes secretions if the client is unable to
coughing, and suction the
effectively clear the airway.
client when needed.

Place the client’s head of bed

This position facilitates optimal ventilation.
elevated.

Supplemental oxygen may be required to maintain

Administer oxygen as ordered.
Pa02 at an acceptable level.

Prepare the client Early intubation and mechanical ventilation are

for mechanical ventilation if recommended to prevent full decompensation of the
oxygen therapy is ineffective. client. Mechanical ventilation provides supportive
care to maintain adequate oxygenation and
 ventilation to the client.

2) Decreased Cardiac Output

Decreased Cardiac Output: Inadequate blood pumped by the heart to meet
metabolic demands of the body.

May be related to

 Cardiac muscle disease.

 Dysrhythmias.
 Increased or decreased preload or afterload.
 Impaired left ventricular (LV) contractility.
 Septal defects.
 Valve dysfunction.

Possibly evidenced by

 Changes in the level of consciousness.

 Crackles, dyspnea, and pulmonary congestion.
 Cyanosis and mottling of the extremities.
 Metabolic acidosis.
 Oliguria and/or anuria.
 Pale, cool, clammy skin.
 Respiratory alkalosis.
 Sustained hypotension with narrowing of pulse pressure.
 Tachycardia.

Desired Outcomes

 Client will maintain adequate cardiac output as evidenced by strong peripheral pulses, HR 60
to 100 beats per minute with regular rhythm, systolic BP within 20 mm Hg of baseline,
urinary output 30 ml hr or greater, warm and dry skin, and normal level of consciousness.

Nursing interventions

Nursing Interventions Rationale

Restlessness and anxiety are early signs of cerebral

Assess for any changes in
hypoxia while confusion and loss of consciousness
the level of consciousness.
Assess the client’s HR, BP,
and pulse pressure. Use
direct intra-arterial
monitoring as ordered.
Assess the cardiac rate,
rhythm, and
electrocardiogram (ECG).
Assess the heart sounds for
gallops ( S 3, S4).
Assess the central and
peripheral pulses.
Assess capillary refill.
Assess respiratory rate,
rhythm, and auscultate
breath sounds.
Monitor oxygen saturation
and arterial blood gasses.
occur in the later stages. Older clients are especially
susceptible to reduced perfusion to vital organs.
Sinus tachycardia and increased arterial BP are seen
in the early stages to maintain an adequate cardiac
output. BP drops as condition deteriorates.
Auscultatory BP may be unreliable secondary to
vasoconstriction. Pulse pressure (systolic minus
diastolic) decreases in shock. Older client have
reduced response to catecholamines; thus their
response to decreased cardiac output may be blunted,
with less increase in HR.
Cardiac dysrhythmias may occur from low perfusion,
acidosis, or hypoxia, as well as from side effects of
cardiac medications used to treat this condition. The
12-lead ECG may provide evidence of myocardial
ischemia (ST-segment and T-wave changes) or
pericardial tamponade (decreased voltage of QRS
complex).
S3 is a classic sign of left ventricular failure and is
produced during passive left ventricular filling when
blood strikes a compliant left ventricle. and
S4is associated with reduced ventricular compliance,
which impairs diastolic filling.
Pulses are weak, with diminished strokevolume and
cardiac output.
Capillary refill is slow and sometimes absent.
Characteristics of a shock include rapid, shallow
respirations and adventitious breath sounds such as
crackles and wheezes.
Pulse oximetry is used in measuring oxygen
saturation. The normal oxygen saturation should be
maintained at 90% or higher. As shock progresses,
aerobic metabolism stops and lactic acidosis occurs,
resulting in the increased level of carbon dioxide and

Monitor the client’s central
venous pressure (CVP),
pulmonary artery diastolic
pressure (PADP),
pulmonary capillary wedge
pressure, and cardiac
output/cardiac index.
Assess fluid balance and
weight gain.
Assess urine output.
Monitor the following
laboratory:
 Potassium.
 Magnesium.
Provide electrolyte
replacement as prescribed.
Restrict fluids
and sodium as ordered if
increased preload becomes
a problem.
Administer IV fluids for
clients with a decreased
preload.
Administer oxygen as
prescribed.
Administer medications as
decreasing pH.
CVP provides information on filling pressures of the
right side of the heart; pulmonary artery diastolic
pressure and pulmonary capillary wedge pressure
reflect left-sided fluid volumes. Cardiac output
provides an objective number to guide therapy.
Fluid and sodium retention occurs 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.
Hypomagnesemnia and Hypokalemia can lead to the
development of dysrhythmias which can further
reduce cardiac output.
Electrolyte imbalance may cause dysrhythmias or
other pathological states.
Fluid resuscitation reduces extracellular fluid volume
and decreases cardiac workload.
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. Pulmonary capillary wedge pressure guides
therapy.
Oxygen may be required to maintain oxygen
saturation above 90% or as indicated by order or
protocol.
Medication therapy is more effective when initiated
prescribed: early. The goal is to maintain systolic BP greater
than 90 or 100 mm Hg.
Antidysrrhythmics are used when cardiac anti
Antidysrrhythmics dysrhythmias are further compromising a low output
state.
Diuretics are used when volume overload is
Diuretics
contributing to pump failure.
Inotropics
 Dobutamine Dobutamine is used in the treatment of cardiac
decompensation due to depressed contractility.
Dopamine stimulates beta-1 adrenergic receptors,
 Dopamine resulting in increased cardiac output and
stimulates dopaminereceptors, resulting in
vasodilatation.
 Inamrinone Inamrinone is a phosphodiesterase inhibitor with
positive inotropic and vasodilator activity.
Norepinephrine stimulates beta1- and alpha-
 Norepinephrine (L
adrenergic receptors, resulting in increased
evophed) cardiac muscle contractility, heart rate, and
vasoconstriction.
Morphine decreases pain, which reduces
Morphine sympathetic stress and provides some preload
reduction.
Vasodilators
NTG causes relaxation of vascular smooth muscle by
 Nitroglycerin (NT
stimulating intracellular cyclic guanosine
G) monophosphate production resulting in a decrease in
preload and blood pressure
Sodium Nitroprusside increase cardiac output by
 Sodium Nitropruss
decreasing afterload and produces peripheral and
ide (Nipride) systemic vasodilation by direct action to the smooth
muscles of the blood vessels.
Mechanical assist device such as VAD or IABP
Institute an intra-aortic
temporarily helps the pumping action of the heart in
balloon pump (IABP) or
order to improve cardiac output. These devices are
ventricular assist device
used in client’s who do not respond to the medical
(VAD) if mechanical
management. IABP increases myocardial oxygen
assistance by
supply and decreases myocardial workload through
counterpulsation is
increased coronary artery perfusion. The
indicated.
client’s stroke volume increases thereby improving
 perfusion to the vital organs.
Prepare the client for
Acute valvular problems or septal defects often
surgical intervention if
require surgical treatment.
ordered.

3) Ineffective Tissue Perfusion

Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to
nourish the tissues at the capillary level.

May be related to

 Reduction/cessation of blood flow.

Possibly evidenced by

 Abnormal ABG’s.
 Altered mentation
 Capillary refill longer than 3 seconds.
 Cyanosis.
 Dysrhythmias.
 Dyspnea.
 Oliguria.

Desired Outcomes

 Client will demonstrate increased perfusion as individually appropriate as

evidenced by strong peripheral pulses, HR 60 to 100 beats per minute with
regular rhythm, systolic BP within 20 mm Hg of baseline, balanced intake and
output, warm and dry skin, and alert/oriented.

Nursing interventions

Nursing Interventions Rationale

Assess the client’s HR, BP,
and pulse pressure. Use direct
intra-arterial monitoring as
ordered.
Sinus tachycardia and increased arterial BP are
seen in the early stages to maintain an adequate
cardiac output. BP drops as condition deteriorates.
Auscultatory BP may be unreliable secondary to
vasoconstriction. Pulse pressure (systolic minus
 diastolic) decreases in shock.

Restlessness and anxiety are early signs of

Assess for any changes in the
cerebral hypoxia while confusion and loss of
level of consciousness.
consciousness occur in the later stages.

Assess capillary refill. Capillary refill is slow and sometimes absent.

Pulse oximetry is used in measuring oxygenation

Monitor oxygen saturation and
arterial blood gasses.
concentration. The normal oxygen saturation
should be maintained at 90% or higher. As shock
progresses, aerobic metabolism stops and lactic
acidosis occurs, resulting in the increased level of
carbon dioxide and decreasing pH.

Restrict the patient’s activity,

Minimize oxygen demand by maintaining bed rest
and maintain the client on a bed
and limiting the client’s activity.
rest.

Oxygen is administered to increase the amount of

Provide oxygen therapy as
oxygen carried by available hemoglobin in the
indicated.
blood.

Sufficient fluid intake maintains adequate filling

Administer IV fluids as
pressures and optimizes cardiac output needed
ordered.
for tissue perfusion.

4) Excess Fluid Volume

Excess Fluid Volume: Increased isotonic fluid retention

May be related to

 Decrease in renal organ perfusion.

 Increased sodium and water retention.
 Hydrostatic pressure increase or decrease plasma proteins.
Possibly evidenced by

 Changes in mental status.

 Cough.
 Crackles.
 Dyspnea.
 Edema.
 Jugular vein distention.
 Oliguria.
 Orthopnea.
 Pulmonary congestion.
 Shortness of breath.
 Weight gain.

Desired Outcomes

 Client will have stable fluid volume as evidenced by balanced intake and
output, stable weight, vital signs within normal limits, and absence of
edema.

Nursing interventions

Nursing Interventions Rationale

Monitor urine output, observe its Urine output may be concentrated and scanty
color and amount. due to decreased renal perfusion.

Auscultate the lung for the

presence of adventitious breath These may indicate pulmonary edema from a
sound such as crackles, wheezing. worsening pulmonary congestion and
Note for presence of cough, intervention must be done immediately.
dyspnea, or orthopnea.

Decreased cardiac output may lead to

decreased renal perfusion and impairment
Monitor client’s intake and output.
with excess fluid volumewhich causes water
and sodium retention and oliguria.

Assess for edema. Edema (usually pitting edema) that starts in

the feet and ankles and gradually lead to
 weight gain.

Fluid and sodium retention occurs due to the

Assess fluid balance and weight compromised regulatory mechanisms. Body
gain. weight is used to detect response to diuretic
therapy.

Jugular vein distention may indicate fluid

Assess for distended neck veins.
excess.

Monitor client’s electrolyte levels Hypokalemia can occur since diureticspromote

esp. potassium. renal potassium secretion.

Review chest radiographs to evaluate the

Monitor client’s Chest x-ray. client’s progress or a worsening lung
condition.

Semi fowler’s position increases

Place the client in a semi position. renal filtration and decreases the production of
ADH thus promoting diuresis.

Repositioning promotes enhanced breathing,

Frequently change the client’s
decreases pressure ulcer and mobilization of
position at least every 2 hours.
secretions.

Instruct the client to have a low Low sodium diet can decrease fluid and
sodium diet. electrolyte retention.
Administer diuretics (e.g., furosem Diuretics decrease plasma volume and
ide) as indicated. peripheral edema.

5) Anxiety

Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic

response.

May be related to

 Change in health status.

  Fear of death.
 Guarded prognosis; mortality rate 80%.
 Unfamiliar environment.

Possibly evidenced by

 Agitation.
 Avoid looking at equipment or keeps vigilant watch over equipment.
 Increased questioning.
 Increased awareness.
 Sympathetic stimulation.
 Verbalized anxiety.
 Uncooperative behavior.

Desired Outcomes

 Client will use effective coping mechanisms.

 Client will describe reduction in level of anxiety experienced

Nursing interventions

Nursing Interventions Rationale

Anxiety and ways of decreasing perceived anxiety are

highly individualized. Interventions are most effective
Assess previous coping
when they are consistent with the client’s established
mechanism used.
coping pattern. However, in the acute care setting
these techniques may no longer be feasible.

Shock can result in an acute life-threatening situation

Assess the client’s level of
that will produce high levels of anxiety in the client as
anxiety.
well as in significant others.

Explain all procedures as Information helps reduce anxiety. Anxious clients

appropriate, keeping unable to understand anything more than simple,
explanations basic. clear, brief instructions.

Encourage the client to Talking about anxiety-producing situations and

verbalized his or her anxious feelings can help the client perceive the
feelings. situation in a less threatening manner.
 Acknowledgement of the client’s feelings validates
Acknowledge an awareness
the client’s feelings and communicates acceptance of
of the client’s anxiety.
those feelings.

Reduce unnecessary
external stimuli by
maintaining a quite
Anxiety may escalate with excessive conversation,
environment. If medical
noise, and equipment around the client.
equipment is a source of
anxiety, consider providing
sedation to the client.

Maintain a confident,
assured manner while
The staff’s anxiety may be easily perceived by the
interacting with the client.
client. The client’s feeling of stability increases in a
Assure the client and
calm and non-threatening atmosphere. The presence
significant others of close,
of a trusted person may help the client feel less
continuous monitoring that
threatened.
will ensure prompt
intervention.