PLT COLLEGE INC.

College of Nursing
Bayombong, Nueva Vizcaya

Nursing Care Management 103 (Care of the Clients with Cardiovascular & Hematologic
Diseases)

CARDIOVASCULAR DISEASES (Part 2)

1. CARDIOGENIC SHOCK
Vic was involved in a car accident. He was rushed to the nearest emergency
department as he is bleeding profusely. Upon arrival, his blood pressure has
dropped, his heart rate and respirations are rapid, and his skin is cold and
clammy. His output is decreased and he is disoriented. Vic is suffering
from hypovolemic shock due to active fluid loss

Hypovolemic shock is one of the most common cardiac complications.

In hypovolemic shock, reduced intravascular blood volume causes circulatory
dysfunction and inadequate tissue perfusion.
Vascular fluid volume loss causes extreme tissue hypoperfusion.

Pathophysiology
 Fluid loss. Fluid loss can either be internal or external fluid loss.
 Compensatory mechanism.The resulting drop in the arterial blood pressure
activates the body’s compensatory mechanisms in an attempt to increase the
body’s intravascular volume.
 Venous return. Diminished venous return occurs as a result of the decrease in
arterial blood pressure.
 Preload. The preload or the filling pressure becomes reduced.
 Stroke volume. The stroke volume is decreased.
 Cardiac output.Cardiac output is decreased because of the decrease in stroke
volume.
 Arterial pressure.Reduced mean arterial pressure follows as the cardiac output
gradually decreases.
 Compromised cell nutrients. As the tissue perfusion decreases, the delivery of STUDY.STUDY.STUDY…princerenerpera
nutrients and oxygen to the cells are decreased, which could ultimately lead to
multiple organ dysfunction syndrome.

Causes
Hypovolemic shock usually results from acute blood loss- about one-fifth of the total
volume.
Internal fluid loss. Internal fluid losses can result from hemorrhage or third-
space fluid shifting.
External fluid loss. External fluid loss can result from severe bleeding or from
severe diarrhea, diuresis, or vomiting.

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 Inadequate vascular volume. Inadequate vascular volume leads to
decreased venous return and cardiac output.

Clinical Manifestations
Hypotension. Hypovolemic shock produces hypotension with narrowed pulse
pressure.
Cognitive. The patient experiences decreased sensorium.
Tachycardia. The body compensates for the decreased cardiac output by
pumping faster than normal, resulting in tachycardia.
Rapid, shallow respirations. Due to the decrease in oxygen delivery around
the body systems, the respiratory system compensates by rapid, shallow
respirations.
Oliguria. There is oliguria or decreased urine output of less than 25ml/hour.
Clammy skin. The patient develops cool, clammy, and pale skin.

Prevention
For prevention of hypovolemic shock, the following must be implemented:
Early detection. Recognize patients with conditions that reduce blood volume as
at-risk patients.
Accurate I&O. Estimate fluid loss and replace, as necessary, to prevent
hypovolemic shock.

Complications
Hypovolemic shock, if left untreated, would result to the following complications:
Acute respiratory distress syndrome.Acute respiratory distress syndrome occurs
when fluid builds up in the tiny, elastic air sacs in the lungs.
Acute tubular necrosis. Acute tubular necrosis is a kidney disorder involving
damage to the tubule cells of the kidneys, which can lead to acute kidney
failure.
Disseminated intravascular coagulation. Disseminated intravascular
coagulation is a pathological process characterized by a widespread
activation of the clotting cascades that results in the formation of blood clots
in the small blood vessels.
Multiple organ dysfunction syndrome. Multiple organ dysfunction syndrome is
the end result of hypovolemic shock.

Assessment and Diagnostic Findings STUDY.STUDY.STUDY…princerenerpera

No single symptom or diagnostic test establishes the diagnosis or severity of shock.
Laboratory findings. There is elevated potassium, serum lactate, and blood
urea nitrogen levels.
Urine characteristics.The urine specific gravity and urine osmolality are
increased.
Blood considerations. Decreased blood pH, partial pressure of oxygen, and
increased partial pressure of carbon dioxide.

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Medical Management
Emergency treatment measures must include prompt and adequate fluid and
blood replacement to restore intravascular volume and raise blood pressure.
1. Volume expansion. Saline solution or lactated Ringer’s solution, then possibly
plasma proteins or other plasma expanders, may produce adequate volume
expansion until whole blood can be matched.
2. Pneumatic antishock garment. A pneumatic antishock garment
counteracts bleeding and hypovolemia by slowing or stopping
arterial bleeding; by forcing any available blood from the lower body to
the brain, heart, and other vital organs; and by preventing return of the
available circulating blood volume to the legs.
3. Treat underlying cause. If the patient is hemorrhaging, efforts are made to stop
the bleeding or if the cause is diarrhea or vomiting, medications to treat
diarrhea and vomiting are administered.
4. Redistribution of fluid. Positioning the patient properly assists fluid redistribution,
wherein a modified Trendelenburg position is recommended in hypovolemic
shock.
5. Pharmacologic Therapy
6. If fluid administration fails to reverse hypovolemic shock, the following are given:
7. Vasoactive drugs. Vasoactive drugs that prevent cardiac failure are given.
8. Insulin is administered if dehydration is secondary to hyperglycemia.
9. Desmopressin (DDAVP). Desmopressin is administered for diabetes insipidus.
10. Antidiarrheal drugs. If dehydration is due to diarrhea, antidiarrheal medications
are administered.
11. Antiemetics. If the cause of diarrhea is vomiting, antiemetics are given.

Nursing Management
1. Nursing Assessment
2. Assessment of the following is vital in hypovolemic shock:
3. History. The history is vital in determining the possible causes and in determining
the work-up.
4. Vital signs. Vital signs, prior to arrival at the emergency department, should also
be noted.
5. Trauma. In patients with trauma, determine the mechanism of injury and any
information that may heighten suspicion of certain injuries.

Nursing Diagnosis STUDY.STUDY.STUDY…princerenerpera

Based on the assessment data, the major nursing diagnoses are:
Risk for metabolic acidosis related to a decrease in the amount of blood in
the capillaries.
Deficient fluid volume related to active fluid loss.
Ineffective tissue perfusion
Self-care deficit related to physical weakness.
Anxiety

Nursing Care Planning & Goals

Maintain fluid volume at a functional level.
Report understanding of the causative factors of fluid volume deficit.

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 Maintain normal blood pressure, temperature, and pulse.
Maintain elastic skin turgor, most tongue and mucous membranes, and
orientation to person, place, and time.
Nursing Interventions
Nursing care focuses on assisting with treatment targeted at the cause of the shock
and restoring intravascular volume.
Safe administration of blood. It is important to acquire blood specimens
quickly, to obtain baseline complete blood count, and to type and
crossmatch the blood in anticipation of blood transfusions.
Safe administration of fluids. The nurse should monitor the patient closely for
cardiovascular overload, signs of difficulty of breathing, pulmonary
edema, jugular vein distention, and laboratory results.
Monitor weight. Monitor daily weight for sudden decreases, especially in the
presence of decreasing urine output or active fluid loss.
Monitor vital signs. Monitor vital signs of patients with deficient fluid volume
every 15 minutes to 1 hour for the unstable patient, and every 4 hours for the
stable patient.
Oxygen administration. Oxygen is administered to increase the amount of
oxygen carried by available hemoglobin in the blood.

2. CARDIOGENIC SHOCK
Mr. Barasi was admitted due to myocardial infarction. Two hours after the
admission, his skin became cool and clammy. Latest BP shows a decrease in the
systolic blood pressure. His heart rate and respirations are gradually increasing,
and his urine output is decreasing. Mr. Barasi is experiencing cardiogenic
shock due to myocardial infarction.

Cardiogenic shock is also sometimes called “pump failure”.

Cardiogenic shock is a condition of diminished cardiac output that
severely impairs cardiac perfusion.
It reflects severe left-sided heart failure.

Pathophysiology
 Inability to contract. When the myocardium can’t contract sufficiently to
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maintain adequate cardiac output, stroke volume decreases and the
heart can’t eject an adequate volume of blood with each contraction.
 Pulmonary congestion.The blood backs up behind the weakened left
ventricle, increasing preload and causing pulmonary congestion.
 Compensation. In addition, to compensate for the drop in stroke volume,
the heart rate increases in an attempt to maintain cardiac output.
 Diminished stroke volume.As a result of the diminished stroke volume,
coronary artery perfusion and collateral blood flow is decreased.
 Increased workload. All of these mechanisms increase the heart’s workload
and enhance left-sided heart failure.

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  End result. The result is myocardial hypoxia, further decreased cardiac
output, and a triggering of compensatory mechanisms to prevent
decompensation and death.

Classification
The causes of cardiogenic shock are known as either coronary or non-coronary.
1. Coronary. Coronary cardiogenic shock is more common than noncoronary
cardiogenic shock and is seen most often in patients with acute myocardial
infarction.
2. Non-coronary. Noncoronary cardiogenic shock is related to conditions that
stress the myocardium as well as conditions that result in an ineffective
myocardial function.

Statistics and Incidences

Cardiogenic shock could be fatal if left untreated.
 Cardiogenic shock occurs as a serious complication in 5% to 10% of
patients hospitalized with acute myocardial infarction.
 Historically, mortality for cardiogenic shock had been 80% to 90%, but
recent studies indicate that the rate has dropped to 56% to 67% due to the
advent of thrombolytics, improved interventional procedures, and better
therapies.
 Incidence of cardiogenic shock is more common in men than in women
because of their higher incidence of coronary artery disease.

Causes
Cardiogenic shock can result from any condition that causes significant left
ventricular dysfunction with reduced cardiac output.
1. Myocardial infarction (MI).Regardless of the underlying cause, left
ventricular dysfunction sets in motion a series of compensatory mechanisms
that attempt to increase cardiac output, but later on leads to deterioration.
2. Myocardial ischemia. Compensatory mechanisms may initially stabilize the
patient but later on would cause deterioration with the rising demands of
oxygen of the already compromised myocardium.
3. End-stage cardiomyopathy.The inability of the heart to pump enough
blood for the systems causes cardiogenic shock.

Clinical Manifestations STUDY.STUDY.STUDY…princerenerpera

Cardiogenic shock produces symptoms of poor tissue perfusion.
 Clammy skin. The patient experiences cool, clammy skin as the blood
could not circulate properly to the peripheries.
 Decreased systolic blood pressure.The systolic blood pressure decreases to
30 mmHg below baseline.
 Tachycardia. Tachycardia occurs because the heart pumps faster than
normal to compensate for the decreased output all over the body.
 Rapid respirations. The patient experiences rapid, shallow respirations
because there is not enough oxygen circulating in the body.
 Oliguria. An output of less than 20ml/hour is indicative of oliguria.

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  Mental confusion. Insufficient oxygenated blood in the brain could
gradually cause mental confusion and obtundation.
 Cyanosis. Cyanosis occurs because there is insufficient oxygenated blood
that is being distributed to all body systems.

Assessment and Diagnostic Findings

Diagnosis of cardiogenic shock may include the following diagnostic tests:
1. Auscultation. Auscultation may detect gallop rhythm, faint heart sounds
and, possibly, if the shock results from rupture of the ventricular septum or
papillary muscles, a holosystolic murmur.
2. Pulmonary artery pressure (PAP).PAP monitoring may show increase in PAP,
reflecting a rise in left ventricular end-diastolic pressure and increased
resistance to the afterload.
3. Arterial pressure monitoring. Invasive arterial pressure monitoring may
indicate hypotension due to impaired ventricular ejection.
4. ABG analysis. Arterial blood gas analysis may show metabolic acidosis and
hypoxia.
5. Electrocardiography. Electrocardiography may show possible evidence of
acute MI, ischemia, or ventricular aneurysm.
6. Echocardiography. Echocardiography can determine left ventricular
function and reveal valvular abnormalities.
7. Enzyme levels. Enzyme levels such as lactic dehydrogenase, creatine
kinase. Aspartate aminotransferase and alanine aminotransferase may
confirm MI.

Medical Management
The aim of treatment is to enhance cardiovascular status by:
Oxygen. Oxygen is prescribed to minimize damage to muscles and organs.
Angioplasty and stenting. A catheter is inserted into the blocked artery to
open it up.
Balloon pump. A balloon pump is inserted into the aorta to help blood flow
and reduce workload of the heart.
Pain control. In a patient that experiences chest pain, IV morphine is
administered for pain relief.
Hemodynamic monitoring.An arterial line is inserted to enable accurate

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and continuous monitoring of BP and provides a port from which to obtain
frequent arterial blood samples.
Fluid therapy.Administration of fluids must be monitored closely to detect
signs of fluid overload.

Pharmacologic Therapy
IV dopamine. Dopamine, a vasopressor, increases cardiac output, blood
pressure, and renal blood flow.
IV dobutamine. Dobutamine is an inotropic agent that increase myocardial
contractility.
Norepinephrine. Norepinephrine is a more potent vasoconstrictor that is
taken when necessary.

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 IV nitroprusside. Nitroprusside is a vasodilator that may be used with a
vasopressor to further improve cardiac output by decreasing peripheral
vascular resistance and reducing preload.

Surgical Management
When the drug therapy and medical procedures don’t work, then the last option
is for surgical procedure.
Intra-aortic balloon pump (IABP).The IABP is a mechanical-assist device that
attempts to improve the coronary artery perfusion and decrease cardiac
workload through an inflatable balloon pump which is percutaneously or surgically
inserted through the femoral artery into the descending thoracic aorta.

Nursing Management
Cardiogenic shock needs rapid, accurate nursing management.

Nursing Assessment
Vital signs. Assess the patient’s vital signs, especially the blood pressure.
Fluid overload.The ventricles of the heart cannot fully eject the volume of
blood at systole, so fluid may accumulate in the lungs.
Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses are:
Decreased cardiac output related to changes in myocardial
contractility/inotropic changes
Impaired gas exchange related to changes in alveolar-capillary membrane.
Excess fluid volume related to a decrease in renal organ perfusion,
increased sodium and water, hydrostatic pressure increase, or decrease
plasma protein.
Ineffective tissue perfusion related to reduction/cessation of blood flow.
Acute pain related to ischemic tissues secondary to blockage or narrowing
of coronary arteries.
Activity intolerance related to imbalance between the oxygen supply and
needs.

Nursing Care Planning & Goals

 Prevent recurrence of cardiogenic shock.

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 Monitor hemodynamic status.
 Administer medications and intravenous fluids.
 Maintain intra-aortic balloon counterpulsation.

Nursing Interventions
1. Prevent recurrence. Identifying at-risk patients early, promoting adequate
oxygenation of the heart muscle, and decreasing cardiac workload can
prevent cardiogenic shock.
2. Hemodynamic status. Arterial lines and ECG monitoring equipment must be
well maintained and functioning; changes in hemodynamic, cardiac, and
pulmonary status and laboratory values are documented and reported; and
adventitious breath sounds, changes in cardiac rhythm, and other abnormal
physical assessment findings are reported immediately.

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3. Fluids. IV infusions must be observed closely because tissue necrosis and
sloughing may occur if vasopressor medications infiltrate the tissues, and it is
also necessary to monitor the intake and output.
4. Intra-aortic balloon counterpulsation. The nurse makes ongoing timing
adjustments of the balloon pump to maximize its effectiveness by synchronizing
it with the cardiac cycle.
5. Enhance safety and comfort. Administering of medication to relieve chest pain,
preventing infection at the multiple arterial and venous line insertion sites,
protecting the skin, and monitoring respiratory and renal functions help in
safeguarding and enhancing the comfort of the patient.
6. Arterial blood gas.Monitor ABG values to measure oxygenation and detect
acidosis from poor tissue perfusion.
7. Positioning. If the patient is on the IABP, reposition him often and perform
passive range of motion exercises to prevent skin breakdown, but don’t flex the
patient’s “ballooned” leg at the hip because this may displace or fracture the
catheter.

“It’s Not Whether You Get Knocked Down,

It’s Whether You Get Up.”

STUDY.STUDY.STUDY…princerenerpera

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 PLT COLLEGE INC.
College of Nursing
Bayombong, Nueva Vizcaya

Nursing Care Management 103 (Care of the Clients with Cardiovascular & Hematologic
Diseases)

WORKING PAPER
I. Kindly answer the following questions. Write your answers on a yellow paper. (10 points
each)

1. Differentiate the etiology and clinical manifestations and the collaborative care and
nursing management of the patient with infective endocarditis and pericarditis.
2. Describe the etiology, clinical manifestations and the collaborative care and nursing
management of the patient with myocarditis.
3. Differentiate the etiology, pathophysiology, and clinical manifestations of rheumatic
fever and rheumatic heart disease.
4. Relate the pathophysiology to the clinical manifestations and diagnostic studies for
the various types of valvular heart disease.
5. Relate the pathophysiology to the clinical manifestations and diagnostic studies for
the different types of cardiomyopathy.

II. Compare & differentiate the various Valvular Heart Diseases in a diagram using
the following criteria: (50 Points)

Mitral Mitral Aortic Aortic

Stenosis Regurgitation Stenosis Regurgitation
Etiology
Pathogenesis
Signs & Symptoms
Type of Murmur

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Changes in ECG
What to notice in an X-ray
Surgical Intervention
Medications
Nursing Management
Nursing Diagnosis (Priority)

Deadline: Next Meeting