Critical care case study - Cardiogenic shock: Nursing

Nurse Raven works in the intensive care unit, or ICU, and is caring for Deirdre, a 72-year-old diagnosed with cardiogenic shock. Nurse Raven goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Deirdre’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Raven recognizes important cues, including Deirdre’s vital signs which are temperature 98.9 F, or 37.2 C; heart rate 111 beats per minute; respirations 24 breaths per minute; blood pressure 80/40 mmHg with a mean arterial pressure, or MAP, of 60 mmHg; and oxygen saturation 89 percent via mechanical ventilation.

Upon assessment, Nurse Raven notes Deirdre’s peripheral pulses are weak; her skin is pale and cool; and dobutamine is infusing through a central line, along with a sedative and paralytic. She also notes Dierdre’s urinary output was 20 milliliters in the last hour.

Next, Nurse Raven analyzes these cues. She reviews the electronic health record, or EHR, and notes Deirdre’s admitting diagnosis was myocardial infarction, or MI, and she underwent immediate percutaneous coronary intervention, or PCI.

Nurse Raven knows that cardiogenic shock is a life-threatening condition where the heart is unable to effectively pump blood to supply the body’s needs that can occur following conditions that cause myocardial dysfunction, like an MI where ischemia results in death of the myocardium, or heart muscle. This impairs contractility, decreases stroke volume, and reduces cardiac output, leading to impaired tissue perfusion and decreased oxygen delivery.

As cardiac output decreases, hypotension occurs, peripheral pulses weaken, and the skin becomes cool and pale as blood is diverted to critical organs.

Also, blood begins to back up into the pulmonary circulation, resulting in pulmonary edema and impaired gas exchange, which further impairs oxygenation of tissues. To compensate, the heart rate and respiration increases in an attempt to improve oxygen delivery to the body. Additionally, urinary output decreases as blood flow to the kidneys is reduced.

Nurse Raven knows that cardiogenic shock can result in severe hypoxia, multiple organ failure, and death if left untreated.