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 BPM respirations, 24 breaths per minute BP, 80/40 millimeters of mercury with a mean arterial pressure or a map of 60 millimeters of mercury and oxygen saturation.

89% 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 a paralytic. She also notes Deirdre's urinary output was 20 mL 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 m 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 bodys 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. Nurse, Raven recognizes that Deirdre needs prompt management of cardiogenic shock to promote effective tissue perfusion.

Now, using the information she's gathered, nurse Raven chooses a priority hypothesis of reduced cardiac output. Then she generates solutions to address Deirdre's impaired cardiac output including pharmacologic and nonpharmacologic interventions.

And she establishes the expected outcome that after intervening Deirdre's map will remain above 65 millimeters of mercury during her shift.

Then nurse Raven takes action to implement these solutions. She notes orders from the healthcare provider including an order to titrate the dobutamine to maintain a map greater than 65 millimeters of mercury and to notify the healthcare provider immediately.

If Deirdre doesn't respond to the medication, there are additional orders for respiratory therapy to titrate the ventilator to maintain oxygen saturation.

Above 92%. Nurse, Raven calls respiratory therapy to adjust Deirdre's ventilator settings, then adjusts the dobutamine infusion following safe medication administration principles.

She covers Deirdre with a warm blanket and ensures the head of the bed is at 30 degrees to promote perfusion and allow for lung expansion.

Nurse Raven ensures that the cardio respiratory monitor is measuring Deirdre's heart rate and rhythm respirations and oxygen saturation continuously and that her BP will be taken every five minutes.

She then reassesses Deirdre BP noting it has increased to 82/42 mmhg with a map of 62 mmhg of me since titr the infusion five minutes ago, nurse Raven titrates the infusion once more using the principles of safe medication administration and plans to reassess diarra's response routinely.

At the end of her shift. Nurse Raven evaluates the outcomes of her actions.

She takes Deirdre's vital signs which are BP. 93/54 millimeters of mercury with a map of 67 millimeters of mercury.

Heart rate, 105 BPM, respirations, 18 breaths per minute and oxygen saturation. 95% via mechanical ventilation.

She notes Deirdre pulses are stronger. Her skin is warm and urine output for the last hour was 32 mL.

Additionally, Deirdre's map remained above 65 mmhg of after adjusting the dobutamine infusion a second time. All right.

As a quick recap, nurse Raven recognized and analyzed cues related to Deirdre's reduced cardiac output, un prioritized hypotheses and generated solutions to address this problem.

Nurse Raven then implemented pharmacologic and nonpharmacologic measures to manage Deirdre cardiogenic shock and evaluated the outcomes compared with the expected outcomes.

Since Deirdre's map remained above 65. Mmhg of nurse Raven determined the plan of care was