Polish up on client care

emergency cart with a defibrillator at the

bedside. Make sure the equipment is turned
on and ready for immediate use to avoid
treatment delay.
Position the client at a 45- to 60-degree
angle. Connect the precordial ECG lead to the
hub of the aspiration needle with an alligator
clamp and connecting wire. When the needle
touches the myocardium during fluid aspiration, an ST-segment elevation or premature
ventricular contractions will be seen. Monitoring the clients ECG ensures accuracy of the
procedure and helps prevent complications.
Monitor blood pressure and CVP during
and after pericardiocentesis to monitor for
complications such as hypotension, which may
indicate cardiac chamber puncture.
Infuse I.V. solutions to maintain blood
pressure. Watch for a decrease in CVP and
a concomitant rise in blood pressure, which
indicate relief of cardiac compression.
Watch for complications of pericardiocentesis, such as VF, vasovagal response, and
coronary artery or cardiac chamber puncture,
to prevent or rapidly treat crisis.
Closely monitor ECG changes, blood
pressure, pulse rate, level of consciousness,
and urine output to detect signs of decreased
cardiac output.

If the client needs a thoracotomy

Explain the procedure to the client.
Tell him what to expect postoperatively
(chest tubes, chest tube drainage system,
administration of oxygen). Teach him how to
turn, deep-breathe, and cough to prevent postoperative complications and relieve the clients
anxiety.
Give antibiotics to prevent or treat infection
and protamine sulfate or vitamin K as needed
to prevent hemorrhage.
Postoperatively, monitor critical parameters, such as vital signs and ABG levels, and
assess heart and breath sounds to detect early
signs of complications such as reaccumulation
of fluid.
Give pain medication as needed to alleviate
pain and promote comfort.
Maintain the chest tube drainage system
and be alert for complications, such as hemorrhage and arrhythmias, to prevent further
decompensation.

313419NCLEX-RN_Chap03.indd 41

Teaching topics
Explanation of the disorder and treatment
plan
Medications and possible adverse effects
Alerting the nurse if condition worsens

Cardiogenic shock

41

A post-MI
client exhibits
cold, clammy skin;
hypotension; oliguria;
and tachycardia.
Hmmmm. Probably
adds up to
cardiogenic shock.

Cardiogenic shock occurs when the heart

fails to pump adequately, thereby reducing
cardiac output and compromising tissue
perfusion.
Heres how cardiogenic shock progresses:
Decreased stroke volume results in
increased left ventricular volume.
Blood pooling in the left ventricle
backs up into the lungs, causing pulmonary
edema.
To compensate for a falling cardiac output,
heart rate and contractility increase.
These compensating mechanisms increase
the demand for myocardial oxygen.
An imbalance between oxygen supply
and demand results, increasing myocardial
ischemia and further compromising the
hearts pumping action.

CAUSES

Advanced heart block

Cardiomyopathy
Heart failure
MI
Myocarditis
Papillary muscle rupture

ASSESSMENT FINDINGS
Anxiety, restlessness, disorientation, and
confusion
Cold, clammy skin
Crackles in lungs
Hypotension (systolic pressure below
90 mm Hg)
Narrow pulse pressure
Jugular vein distention
Oliguria (urine output of less than 30 ml/
hour)
Third (S3) and fourth (S4) heart sounds
Tachycardia or other arrhythmias
Tachypnea, hypoxia
Weak, thready pulse

4/8/2010 7:01:42 PM