5 Cardiogenic Shock Nursing Care Plans

Impaired Gas Exchange

In cardiogenic shock, the heart is unable to pump enough blood to meet the body’s needs, leading to decreased blood flow and oxygen delivery to vital organs and tissues. This decrease in oxygen delivery can result in impaired gas exchange, where the body is not able to effectively absorb oxygen from the lungs and release carbon dioxide.

Nursing Diagnosis

• 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.
• Crackles.
• Cyanosis.
• Headache.
• Hypercapnia.
• Hypoxia.
• Tachycardia.

Desired Outcomes

• The 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 Assessment and Rationales

1. 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 hyperventilate. Respiratory failure develops as the client experiences respiratory muscle fatigue and decreased lung compliance.

2. Assess the client’s heart rate and blood pressure.
As shock progresses, the client’s blood pressure and heart rate will decrease and dysrhythmias may occur.

3. Assess for any signs of changes in the level of consciousness.
Headache and restlessness are early signs of hypoxia.

4. 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.

5. 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.

6. 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.

7. 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.

Nursing Interventions and Rationales

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

2. Place the client’s head of the bed elevated.
This position facilitates optimal ventilation.

3. Administer oxygen as ordered.
Supplemental oxygen may be required to maintain PaO₂ at an acceptable level.

4. 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 for the client.