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, and adjust medications and therapies based on the assessment data.
Impaired Gas Exchange
- Impaired Gas Exchange
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.
- 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.
|Assess the client’s respiratory rate, rhythm, and depth.||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. Respiratory failure develops as the client experiences respiratory muscle fatigue and decreased lung compliance.|
|Assess client’s heart rate and blood pressure.||As shock progresses, the client’s blood pressure and heart rate will decrease and dysrhythmias may occur.|
|Assess for any signs of changes in the level of consciousness.||Headache, restlessness are early signs of hypoxia.|
|Auscultate the lung for areas of decreased ventilation and the presence of adventitious sounds.||Moist crackles are caused by increased pulmonary capillary permeability and increased intra-alveolar edema.|
|Assess for cyanosis or pallor by examining the skin, nail beds, and mucous membranes.||Cool, pale skin may be secondary to a compensatory vasoconstrictive response to hypoxemia. Peripheral tissues become cyanotic due to impaired oxygenation and perfusion.|
|Monitor oxygen saturation using pulse oximetry.||Pulse oximetry is used in measuring oxygenation concentration. The normal oxygen saturation should be maintained at 90% or higher.|
|Monitor arterial blood gasses.||Increasing Pac02 and decreasing Pa02 are signs of hypoxemia and respiratory acidosis. As the client’s condition begins to fail, the respiratory rate will decrease and Pac02 will continue to increase.|
|Assist the client when coughing, and suction the client when needed.||Suction removes secretions if the client is unable to effectively clear the airway.|
|Place the client’s head of bed elevated.||This position facilitates optimal ventilation.|
|Administer oxygen as ordered.||Supplemental oxygen may be required to maintain Pa02 at an acceptable level.|
|Prepare the client for mechanical ventilation if oxygen therapy is ineffective.||Early intubation and mechanical ventilation are recommended to prevent full decompensation of the client. Mechanical ventilation provides supportive care to maintain adequate oxygenation and ventilation to the client.|
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans for hematologic and lymphatic system disorders:
- Anaphylactic Shock | 4 Care Plans
- Anemia | 4 Care Plans
- Aortic Aneurysm | 4 Care Plans
- Deep Vein Thrombosis | 5 Care Plans
- Disseminated Intravascular Coagulation | 4 Care Plans
- Hemophilia | 5 Care Plans
- Leukemia | 5 Care Plans
- Lymphoma | 3 Care Plans
- Sepsis and Septicemia | 6 Care Plans
- Sickle Cell Anemia Crisis | 6 Care Plans