Assessment

HISTORY. The patient is likely to have a history of symptoms of an acute MI, including crushing, viselike chest pain or heaviness that radiates to the arms, neck, or jaw, lasting more than 20 minutes and unrelieved by nitroglycerin and rest. Other MI symptoms include shortness of breath, nausea, anxiety, and a sense of impending doom. The patient may also have a history of symptoms of any of the other etiologies mentioned above.

PHYSICAL EXAMINATION. During the initial stage of shock, there are no clinical findings unless the cardiac output can be measured. When the patient has entered the compensatory stage, symptoms may include an altered level of consciousness; sinus tachycardia; the presence of an S3 or S4 gallop rhythm; jugular venous distension; hypotension; rapid, deep respirations; pulmonary crackles; venous oxygen saturation (SvO2) less than 60%; cyanosis; urine output less than 20 mL/hr; decreased urinary sodium; increased urinary osmolarity; peripheral edema; hyperglycemia; hypernatremia; cold, clammy skin; and decreased bowel sounds.

As the patient enters the progressive stage, the symptoms become more pronounced and resistant to treatment. The patient becomes mentally unresponsive; hypotension becomes worse, requiring high doses of positive inotropic agents; metabolic and respiratory acidosis become apparent; oliguria or anuria and anasarca may ensue; and symptoms of DIC may be present. When the shock reaches the refractory stage, multisystem organ failure is apparent, with the above symptoms unresponsive to treatment.

PSYCHOSOCIAL. The patient in cardiogenic shock is in a life-threatening situation. The chances for survival are small, and the patient may experience a sense of impending doom. The impaired tissue perfusion may lead to anxiety and fear. The patient and his or her family or significant other may be in crisis. Both the patient and the family may be experiencing grief in response to the potential loss of life.

Diagnostic Highlights

Anxiety and Panic Attacks

Anxiety and Panic Attacks

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