Respiratory Management and Cardiogenic Shock

This article discusses the respiratory management and cardiogenic shock in detail. It covers the symptoms, causes, and interventions for these conditions. The patient's assessment data is also analyzed to understand the situation better.

Running head: RESPIRATORY MANAGEMENT AND CARDIOGENIC SHOCK
Respiratory management and Cardiogenic Shock
Name of the Student
Name of the University
Author’s Note:

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Answer to the question number 1:
The patient, Mr Ben Long is admitted with very high respiratory rate which is 32. His
chest X-ray confirmed that he has pulmonary oedema. His pH level 7.22 is already lower
than the normal pH range (7.35 – 7.45). This indicates that the Mr Long is deteriorating in to
respiratory acidosis as the patient’s body is not able to get rid of excess amount of CO2
present in the blood. Additionally, the patient’s oxygen saturation (SaO2) level is at 91 per
cent which is already lower than the lower end of the normal range 94%. This signifies that
Mr Long is suffering from hypoxemia. At this stage, the patient, Mr Long should be assessed
on the parameters of complete vital sounds, auscultation of lungs, respiratory status and
cardiac and pulmonary conditions. Additionally, Mr Long should be checked for restlessness,
confusion and cyanosis along with the level of consciousness as immobile state of patient
could be significant of impending respiratory failure and cardiogenic shock. The first
intervention will be to sit the patient in Fowler’s or Semi- Fowler’s position as these positions
allows maximum chest expansion for the patient with minimum effort. This will allow
maximum space for the lungs to expand and which in turn will breathing comparatively
easier (Riviello et al. 2016). As patient has breathing problem and SaO2 is decreasing with
acid- base imbalance in blood, the patient should not be left alone at any conditions as patient
might become unconscious (Narita et al. 2017). The next step will be to assess the skin
temperature and moisture of the patients along with symmetry of the chest expansion. The
nurse should also check for lump or tenderness in any area. The patient is already on the
external O2 supply through face mask at 6 L/ minute rate. The patient should be checked
whether external supply of O2 helping the patient or not. To achieve this a non- invasive
method can be administered to measure the arterial blood saturation for O2. This can be
performed via Pulse Oximetry. Additionally, Electrocardiogram and Pulmonary Function
Tests (PFT) should be performed. Electrocardiogram should be done to check the conduction

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of the heart as the patient is in the risk of cardiogenic shock (Madia 2017). Patient is having
trouble breathing so PFT will be performed to monitor the movement of the lungs. Finally, if
the conditions still deteriorate the patients Fraction of Inspired Oxygen (FiO2) should be
increased. This can be administered by the use of non- invasive respiratory management
system known as Bilevel Positive Airway Pressure (BiPAP). For the administration of this
procedure, following setting can be used. Inspiratory positive airway pressure (IPAP) will be
set at 12 cm H2O and expiratory positive airway pressure (IPAP) will be set at 7 cm H2O. The
Fraction of Inspired Oxygen (FiO2) will be set at 0.4 which denotes 40 per cent oxygen
concentration in the supplied air. IPAP is applied during breathe in and set at higher than the
EPAP, so that it helps opening up the airway. EPAP is administered during the breathing out
and lower pressure during EPAP helps breathing out easier as lungs does not have to work
against such a high pressure.
Patients is having trouble breathing due to pulmonary oedema and BiPAP is very
good non- invasive respiratory management system for this conditions. BiPAP machine
continuously administer two different air pressure through IPAP and EPAP during breathing
in and breathing out. It helps reducing the breathing obstruction by keeping the muscle in the
throat from collapsing. The BiPAP machine has a significant advantages over CPAP
machine. CPAP machine administer a continuous air pressure during both the breathing in
and out. Hence, sometimes patients complains about the trouble during the breathing out as
the lungs have to work against a high pressure during breathing out. The clear advantages of
BiPAP machine is that it applies lower pressure during the breathing out, so patient has easier
and relaxed breathing out experience. The BiPAP machine also has a breathe-timing feature
which suggests the amounts of breathing the patient should be taking (Rong et al. 2016).
The first and foremost nursing interventions for the care management of Mr Long
should be to provide appropriate amount of supplemental oxygen supply and make sure the

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airways of the patient remains clear. Nurses should also be prepared for the quick
administration of intubation as the patient’s conditions can worsen very quickly.
Furthermore, the nurse should make sure that the patient is in the optimal sitting conditions to
enable sufficient amount of lung expansion for easier breathing in and out (Shaikh et al.
2017). Additionally, the nurse should record the complete vital and respiratory status and
document it as early as possible and notify the appointed medical professional for the patient.
Patient is suffering from respiratory acidosis and hypoxemia. Application of Fraction
of Inspired Oxygen (FiO2) at 0.4 should take care of the hypoxemia and able to supply
enough amount of oxygen for the patients need of oxygenation. Application BiPAP should
able to help the patient exercise relatively normal breathing experience which allow the body
to get rid of excess amount of CO2 in the body which should negate the effect of respiratory
acidosis. Therefore, at least in theory, the patient should feel better compared to his previous
condition.
Answer to the question number 2:
From the assessment data of Mr Ben Long it can be seen that the patient has
irregularly high pulse which is 135 beats per minute. This indicates that the patients has high
contractility rate in his heart. From the above data and the symptoms that have been during
the assessment denotes that the patient in going in to a cardiogenic shock. The primary cause
of the cardiogenic arrest is the impairment of cardiac muscle. A decrease in contractile force
signifies that decrease in volume of blood being ejected from the right ventricle of blood. A
decrease in volume of blood being ejected from the right ventricle will decrease the force of
preload in the left ventricle. Preload can be defined as the first contraction of cardiac
myocytes before the start of contraction. Afterload is related to the preload and can be
defined as the load or force needed for the heart to contract for the ejection of blood. A
decrease of preload and blood volume will lower the pressure in systematic arteries and aorta.

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The decrease or reduction of pressure in artery will activate the sympathetic nervous system
and this happens via hypothalamus. This stimulated sympathetic nervous system in turn
increase the contractile force and heart rate. Additionally, body will try to retain the renal
fluid in an effort to increase the arterial pressure and preload, so that the body can restore the
flow of blood (Furer, Wessler and Burkhoff 2017). This situation directly matches with the
assessment data collected form the assessment of the patient, Mr Ben Long. For the situation
facing by the patient, these compensatory mechanism might work against the patient’s
current condition and it might degenerate further the cardiac conditions. Increment in heart
rate and contractile force will in turn increase the myocardial oxygen demand. This
mechanism along with fluid retention might lead to a pulmonary congestion along with a
severe case of hypoxemia. In this case, assessment have already shown that patient has
pulmonary oedema and patient is in critical need of oxygenation. This will increase the
pressure in root of aorta which in turn will create ever more demand of myocardial oxygen
demand and consumption of oxygen in body. From the assessment data, it is evident that
patient has low blood pressure of 78/ 47 mmHg. Low blood pressure is directly correlated
with the low cardiac output. Low cardiac output happens because of increment of systematic
pressure which aggravate the pump failure. This in turn will further reduce the flow of blood
in the coronary vessels. Decreased cardiac output can leads to the ischemic heart and
prolonged state of ischemia will lead to the eventual accumulation of lactic acid. This
condition is known as lactic acidosis. Sustained condition of this lactic acidosis will damage
the cellular membrane irreversibly and eventually it will lead to the total and irreversible loss
of heart’s pump function (Bolfer and Sleeper 2018). The first and foremost assessment of the
cardiogenic shock who have already developed pulmonary oedema is to supply with adequate
oxygen. In case the patient, Mr Ben Long has showed every bit of this symptoms and was
supplied with adequate oxygen. The primary objective in this condition should be to restore

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oxygen level in blood so that the cardiac workload decreased and myocardial oxygen demand
of the body lessens.
Coronary perfusion pressure can be defined as the pressure gradient needed to
maintain the coronary blood pressure. This signifies that the pressure difference between end
diastolic pressure of left ventricular and diastolic aortic pressure. In general, it is also known
as perfusion pressure. Coronary perfusion pressure commonly used in the context of cardiac
failure. A minimum coronary perfusion pressure is needed to maintain the outcome of
successful blood pumping. At the time of cardiac failure, coronary perfusion pressure is
important parameters that should be considered for the return of spontaneous circulation.
From the above discussion, it has already been established that the patient, Mr Long, has very
high heart rate. Increment in heart rate have negative effect on diastolic pressure. During the
time of increased heart rate, it effects diastolic pressure more than the systolic pressure. This
mechanism, in turn, lessens the perfusion time. Oxygen delivery to the cells and tissues in the
body is important for proper functioning. Oxygen delivery is performed by and depend on the
oxygen carrying capability of arteries and myocardial blood flow. Cardiogenic failure can be
a result of lower coronary perfusion time and higher left ventricular end-diastolic pressure
(LVEDP). Systemic vasoconstriction may help to enhance the myocardial perfusion rate but
is also increases myocardial oxygen demand with the body (Napp, Kühn and Bauersachs
2017). During the time of diastole, blood flow resumes as the muscle relaxes. The patient is
suffering high heart rate (135 beats per minute) and very low diastolic pressure (47 mmHg).
Both of this data indicates the condition reflected on the above paragraph which low
perfusion time and low cardiac output.
From discussion above it can be inferred that patients cardiac output is very low at
this current situation. This reduction in cardiac output is generally compensated by the body
in the increase in heart rate mediated by baroreceptor which in turn increases the ventricular

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filling pressure. As a direct consequences of this phenomena, venous pressure increases
which is stimulated by increased blood volume. Pulmonary Oedema can be a direct
consequences of this increased venous pressure (Peng et al. 2014). The patient, Mr Ben Long,
has already been diagnosed with Pulmonary Oedema according to the chest X-ray performed
in him during assessment. This reflexes of baroreceptor does not only increases the heart rate
but also increase the gastrointestinal perfusion rate and renal retention as body trying to
compensate the lack of oxygen supply in body.
Brain is very important part of our body which needs continuous supply of oxygen in
adequate amount. Perfusion pressure or rate in the brain can be affected by the intracranial
pressure or ICP. Generally, during the pathological conditions, increment in intracranial
pressure can restrict the blood flow in brain. From the discussion in the above sections and
assessment data, it can be deduced that patient’s perfusion rate is lower or restricted in the
brain (Tameem and Krovvidi 2013). Adequate supply of oxygen in brain is needed to sustain
consciousness. From the assessment, Mr Ben Long has clearly confused and his level of
consciousness decreased considerably. Hence, it can be said that the adequate oxygen supply
is restricted or obstructed in his brain.

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