Primary Nursing Diagnosis

Altered tissue perfusion (peripheral, cerebral, renal, and cardiopulmonary) related to inadequate cardiac output

OUTCOMES. Circulation status; Cardiac pump effectiveness; Tissue perfusion: Cardiopul-monary, Cerebral, Renal, Peripheral; Vital sign status

INTERVENTIONS. Circulatory care; Emergency care; Vital signs monitoring; Cardiac care; Cardiac precautions; Oxygen therapy; Fluid/electrolyte management; Fluid monitoring; Shock management: Volume, Medication administration, Resuscitation, Surveillance

H PLANNING AND IMPLEMENTATION Collaborative

The primary goal in treating cardiogenic shock is improvement in tissue perfusion and oxygenation. To limit the infarct size and treat the dyspnea, pulmonary congestion, hypoxemia, and acido-sis, the physician is likely to prescribe oxygen. If a previously normocapnic patient's PaCO2 decreases below 50 mm Hg, then the patient may require endotracheal intubation and mechanical ventilation.

Although the patient needs an adequate blood pressure, afterload may also need to be decreased, which may be accomplished with the intra-aortic balloon pump (IABP). A left ventricular assist device (LVAD) may be used to replace the function of the patient's heart for several days to provide total rest for the heart. An LVAD diverts blood from the left atrium or left ventricle by means of a pressure gradient and moves it to the external pump, after which the

188 Cardiogenic Shock blood is returned to the aorta during diastole. An LVAD can reduce the patient's right ventricular contraction. Monitor the patient's central venous pressure carefully.

Pharmacologic Highlights

General Comments: Improving cardiac output, which is necessary to improve tissue perfusion, can be accomplished in several ways. If the patient is able to maintain hemodynamic stability, the physician prescribes medications, namely diuretics and nitrates, to reduce preload. During the later phases of shock, the patient may be too hypotensive to tolerate the vasodilative effects of both diuretics and nitrates.

The patient needs improvement in myocardial contractility without adding significant workload on the heart. Dopamine may also be used in an attempt to improve contractility and cardiac output. Other vasoactive drugs, such as amrinone, may also be used. Vasopressors may be used in an attempt to increase the mean arterial blood pressure to a level that provides adequate tissue perfusion (>70 mm Hg). Several agents that may be administered include dopamine, epinephrine, norepinephrine, and phenylephrine hydrochoride

Medication or Drug Class

Dosage

Description

Rationale

Dobutamine Diuretics

2-40 ^g/kg per minute (but usually in the range of 2-20 ^g/kg per minute); milrinone may be added if patients are not responding or are developing tachycardia in response to dobutamine

Varies by drug thiazide

Sympathomimetic

Loop diuretics,

(preload)

diuretics

Dobutamine improves heart contractility without much effect on heart rate; renal function may also improve through increased cardiac output and renal perfusion

Reduces venous return

Note: Some sources suggest that dopamine is the preferred therapeutic agent in individuals who are hypotensive, and norepinephrine may be required in markedly hypotensive patients (systolic BP, 70 mm Hg)

Note: Some sources suggest that dopamine is the preferred therapeutic agent in individuals who are hypotensive, and norepinephrine may be required in markedly hypotensive patients (systolic BP, 70 mm Hg)

Independent

Limiting myocardial oxygen consumption is a primary concern. Decreasing oxygen demand may limit ischemia, injury, and infarction. Restrict the patient's activity, and maintain the patient on bedrest. Address the patient's anxiety by explaining all procedures. Permit the family or significant others to remain with the patient as long as their presence does not cause added stress. Maintaining a calm and peaceful environment provides reassurance and reduces anxiety, which, in turn, will reduce myocardial oxygen consumption.

Restricted activity could lead to impaired skin integrity, necessitating frequent assessment and care of the skin. Adequate protein and calories are essential for the prevention or healing of impaired skin integrity and should be provided by oral, enteral, or parenteral means.

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