Cues and Priorities
Cause: Most often follows an extensive myocardial infarction (MI) causing pump failure. Other causes include severe cardiomyopathy or mechanical defects (e.g., valve rupture).
Key signs:
- Blood pressure: SBP ≤90 mmHg or sudden drop; narrow pulse pressure
- Pulse/skin: Rapid, weak pulse; cool, clammy, pale skin; possible cyanosis or mottling
- JVD & lungs: Jugular venous distension; crackles/wheezes from pulmonary edema
- Neuro: Confusion, restlessness, anxiety
- Urine output: <30 mL/hr suggests renal hypoperfusion
Hemodynamics: Cardiac index <2.2 L/min/m² and PCWP >15 mmHg define cardiogenic shock.
First priorities (ABCs):
- Secure airway; administer supplemental oxygen
- Continuous BP/HR/ECG monitoring
- Support circulation with inotropes/vasopressors; consider IABP/Impella if needed
- Early reperfusion (PCI) for MI when appropriate
Nursing Care Plan #1: Decreased Cardiac Output
Nursing Diagnosis Statement:
Decreased cardiac output related to impaired ventricular function, as evidenced by hypotension and weak pulses.
Related Factors/Causes:
- Acute MI (loss of myocardial contractility)
- Ventricular dysrhythmias
- Severe cardiomyopathy
Nursing Interventions and Rationales:
- Monitor vital signs & hemodynamics continuously: SBP ≤90 mmHg or narrowing pulse pressure warrants immediate action; continuous ECG detects arrhythmias.
- Administer oxygen and inotropic agents (e.g., dobutamine) as ordered: Improves contractility and supports cardiac output.
- Give vasopressors (e.g., norepinephrine): Maintain SBP >90 mmHg to preserve coronary and organ perfusion.
- Manage IV fluids carefully: Provide fluids if preload is low; avoid overload that worsens pulmonary edema.
- Prepare for emergency measures: Defibrillation and mechanical circulatory support (IABP/Impella) if deterioration occurs.
Desired Outcomes:
- SBP ≥90 mmHg; HR 60–100 bpm
- Strong peripheral pulses; warm skin
- Urine output ≥30 mL/hr
Nursing Care Plan #2: Ineffective Tissue Perfusion (Cardiopulmonary)
Nursing Diagnosis Statement:
Ineffective tissue perfusion (cardiopulmonary) related to low cardiac output, as evidenced by chest pain and fatigue.
Related Factors/Causes:
- Markedly decreased circulation
- Systemic vasoconstriction
Nursing Interventions and Rationales:
- Maintain SpO₂ ≥90% with supplemental oxygen; obtain ABGs as indicated.
- Elevate HOB; encourage deep breathing: Improves lung expansion and oxygenation.
- Administer nitroglycerin as ordered: Reduces preload/afterload and enhances coronary perfusion (monitor BP).
- Assess peripheral perfusion frequently: Capillary refill, skin temperature; report worsening findings promptly.
Desired Outcomes:
- SpO₂ ≥90% on oxygen
- Chest pain relieved; no new ischemic ECG changes
Nursing Care Plan #3: Acute Pain (Chest)
Nursing Diagnosis Statement:
Acute pain (chest) related to myocardial ischemia, as evidenced by the patient’s report of severe chest pressure.
Related Factors/Causes:
- Myocardial infarction (ischemic pain)
- Reduced coronary blood flow
Nursing Interventions and Rationales:
- Administer sublingual nitroglycerin per protocol (up to 3 doses, q5 min, if not contraindicated).
- Give IV morphine as prescribed: Decreases pain/anxiety and lowers myocardial oxygen demand.
- Provide oxygen therapy.
- Minimize activity; keep the patient at rest with the head elevated.
Desired Outcomes:
- Pain ≤3/10
- HR and BP stabilize near baseline
FAQ
What is cardiogenic shock?
A life-threatening state where the heart suddenly fails to pump effectively, causing a critical fall in blood pressure and organ perfusion; most commonly due to a large MI.
What nursing diagnoses are priority?
Decreased Cardiac Output is primary. Also address Ineffective Tissue Perfusion and Acute Pain.
What are priority interventions?
Maintain airway/oxygenation, support circulation with inotropes/pressors, manage fluids carefully, relieve pain/anxiety, and closely monitor hemodynamics. Prepare for reperfusion and mechanical support when indicated.
How do I assess for cardiogenic shock?
Continuous BP/HR/ECG; evaluate perfusion (cool skin, weak pulses, confusion, low urine output), listen for lung crackles, and watch for new arrhythmias or ischemic ECG changes.
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Peer-Reviewed References
- Carpenito, L. J. (2022). Handbook of Nursing Diagnosis (16th ed.). Wolters Kluwer.
- Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2021). Medical-Surgical Nursing (11th ed.). Elsevier.
- Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (15th ed.). Lippincott Williams & Wilkins.
- Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2021). Fundamentals of Nursing (10th ed.). Elsevier.
- O’Gara, P. T., et al. (2013). 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Circulation.