Cardiogenic Shock: Management (Nursing)

by Rhonda Lawes, PhD, RN

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    00:00 Now, let's look at the management of cardiogenic shock.

    00:04 Remember, we're still in Layer 3.

    00:06 We're prioritizing hypotheses, generate solutions, taking action, and then evaluating them.

    00:12 We know the challenge with shock is to correct the underlying cause.

    00:16 And so our management is based on what the underlying cause is.

    00:20 Here are our target goals. Just as a reminder.

    00:22 You want an arterial oxygen saturation of 92 to 95%, which may require oxygen support.

    00:30 So it might be something external like a mask, or the patient may need to be intubated.

    00:35 Our goal here since it is cardiogenic shock, we want to improve cardiac output.

    00:41 So, we may look at like vasodilation, and something to improve contractility.

    00:46 Now, think that through.

    00:47 Vasodilation, how would that help the heart? Well, it's not going to have to work as hard, right? If the vessels are not as constricted, after the heart is pumping out of that left ventricle, this taken a hit, that will be easier for the heart.

    01:01 Improved contractility means we're going to help that heart pump harder more efficiently.

    01:07 Does that make sense for somebody in cardiogenic shock? Yeah, it makes perfect sense.

    01:13 So, vasodilation, and improving contractility are two of our goals in cardiogenic shock.

    01:18 Now, the drug of choice, that's going to vary.

    01:21 It depends on the clinical goal and a thorough understanding of each drugs mechanism of action.

    01:26 We're not going to go into that detail here.

    01:29 But just be aware, those are the goals.

    01:31 Vasodilation, and improving contractility.

    01:34 Keeping in mind, our goal is to improve cardiac output.

    01:37 Let's just look at some major categories of drugs and how they do that.

    01:41 How do they help us improve cardiac output? Nitrates, they take the corner arteries and they dilate them.

    01:48 That's really nice for the heart, right? We wanted to get extra good gentle blood supply.

    01:54 Diuretics, reduce preload, because diuretics cause the patient to pee out extra volume, that means there's less volume in the intravascular space.

    02:05 And if we give them appropriately, that will be less work for the heart, because there'll be a reduced preload coming back to the heart.

    02:12 The vasodilators. They reduce the afterload.

    02:16 The pressure, the heart has to work against as blood as leaving that left ventricle.

    02:21 And remember, in this case, we talked about a left ventricle that had suffered from dead tissue after an MI.

    02:27 Now, beta blockers.

    02:30 These guys are [unintelligible], we use for lots of different things.

    02:33 But in cardiogenic shock, it will decrease the heart rate and decrease the contractility of the heart.

    02:40 So, if the heart is beating slower, and not contracting is hard, it's going to be less work for the heart and should end up in improved cardiac output.

    02:50 Now, study tip, when you're going through.

    02:52 Make sure you can look at these categories of medication and explain why they improve cardiac output on your own.

    03:00 Not by looking at your notes, but seeing if you can retrieve that from yourself.

    03:04 Now, if it gets too bad, the damage or insult to the heart, a heart transplant may be necessary.

    03:10 Now, I have a question for you.

    03:12 Why don't we put the SPO2 sensor on the forehead of a client? Normally that goes on the finger.

    03:18 Well, this patient is in cardiogenic shock.

    03:20 Meaning where his blood started to shunt? Right, to the heart and to the brain, Meaning you're not going to get an accurate reading on the finger.

    03:30 That's why we put it on the forehead when a patient is in shock.

    03:33 Remember, our goals we want to maintain an Mean Arterial Pressure over 65. We want to keep that CVP up, right? We want enough fluid in the body, but we don't want to overload the heart.

    03:46 Now, keep an eye on their electrolytes.

    03:48 Because we were giving them a diuretic, We want to really watch that potassium closely.

    03:52 The loop diuretics, like furosemide, can really be problematic with dropping the potassium.

    03:58 Let's take a look at our shock chart.

    04:01 Now, on the left hand side, you'll see the type of shock.

    04:04 We're going to look at cardiogenic.

    04:05 So, answer these with me as you go through to kind of quiz yourself.

    04:09 So, cardiac output. Which impact would you expect up or down? Well, since we're talking about cardiogenic shock, the output is going to be down.

    04:19 What about the heart rate up or down? That's a compensatory mechanism.

    04:25 So, when cardiac output is down, heart rate is faster, it's increased.

    04:29 CVP. If you see a change, it will be elevated.

    04:33 Now, let me explain why.

    04:35 In cardiogenic shock, the client ends up with fluid overload.

    04:39 And that's what results in an elevated CVP.

    04:42 Because remember, the cardiac pump is not able to get blood through the heart.

    04:48 So, it's going to back up.

    04:50 You might even see venous jugular distension, right, because it's backing up into that venous system.

    04:55 So, keep in mind CVP, if you see a change, it's likely to be up.

    05:00 And you may even assess for jugular vein distension.

    05:03 Now, let's finish up the rest of these.

    05:06 PCWP stands for wedge pressure.

    05:09 It's also going to be elevated because of the fluid volume overload.

    05:13 SVR. What do you -- that's kind of an odd one.

    05:16 That's the systemic vascular resistance.

    05:18 What do you think? Up or down? Actually, this is another compensatory mechanism.

    05:24 Because that cardiac output is down.

    05:27 The body's going to try to constrict those vessels.

    05:29 So, your SVR which is a measurement of that will be up.

    05:33 O2 sat? Yeah, that's a no brainer in shock, isn't it? It's going to be down in this one in cardiogenic shock.

    05:40 Your output is down, your heart rate is up.

    05:43 That's another sign that that oxygen sat is not where we want it to be 92 to 95%.

    05:49 So that's it. You finished our series on cardiogenic shock.

    05:53 Join us for the others.

    About the Lecture

    The lecture Cardiogenic Shock: Management (Nursing) by Rhonda Lawes, PhD, RN is from the course Shock (Nursing).

    Included Quiz Questions

    1. Improve cardiac output
    2. Replace fluid loss
    3. Reduce tissue oxygen demand
    4. Identify the underlying cause
    1. Vasodilation
    2. Improved contractility
    3. Vasoconstriction
    4. Increase pre-load
    5. Increase after-load
    1. By decreasing heart rate
    2. By decreasing contractility of the heart
    3. By increasing heart rate
    4. By increasing blood pressure
    5. By decreasing pre-load

    Author of lecture Cardiogenic Shock: Management (Nursing)

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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