University Nursing Practice: Cardiogenic Shock Case Study Analysis

This report presents a comprehensive analysis of a nursing case study involving a 72-year-old patient, Frank James, admitted with an acute exacerbation of chronic heart failure leading to cardiogenic shock. The report meticulously examines the patient's presentation, including signs and symptoms associated with the ABCDE approach (Airway, Breathing, Circulation, Disability, and Exposure). It delves into the pathophysiology of cardiogenic shock, discussing the underlying causes and manifestations, such as changes in vital signs, respiratory distress, and altered mental status. The report also outlines the nursing interventions, including medication management, fluid administration, and patient positioning to alleviate symptoms and improve outcomes. Furthermore, the report incorporates an ISBAR (Identify, Situation, Background, Assessment, Recommendation) handover format to demonstrate effective communication in a clinical setting. The report also highlights the importance of smoking cessation and lifestyle modifications for long-term patient management. The case study includes references to support the analysis.

Running Head: Integrated nursing practice
Integrated nursing practice
Name of the Student
Name of the University
Author Note

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Introduction
The assignment deals with the case study of Frank James; 72-year-old man has been
admitted due to acute exacerbation of his chronic heart failure. Based on the cardiogenic shock
presented in the case study, the essay discusses the signs and symptoms as associated with the
ABCDE pneumonic. The pathophysiology of the cardiogenic shock and the highlighted signs
and symptoms are discussed critically. Shock is the state of inadequate oxygen delivery to vital
organs of the body and insufficient perfusion throughout the body. It is the life-threatening
situation and requires immediate assessment and treatment (Thiele et al., 2015).
Part A
In the given case study, when Frank James was admitted with an acute exacerbation of
his chronic heart failure. Observation showed he was mildly diaphoretic, slightly short of breath
and complained of nausea. In the last three weeks the patient had experienced pain radiating to
his back every hour, which is relieved with sublingual nitroglycerin (GTN). The patient has
family history of heart disease. He was under medication of aspirin, atenolol, isosorbide, and
lisinopril. On the next morning the patient complained of shortness of breath and restlessness
with a chest pain score of 2/10 that is radiating to his left arm. Upon chest X ray, it was found
that his cardiac condition was worsening with pulmonary oedema. On examination, he is
confused, sweating, pale and centrally cyanosed.
The common causative factors of cardiogenic shock are myocardial infarction,
Cardiomyopathy, Valve disease, Structural defects and Cardiac arrthymias. The common cause
of the cardiogenic shock is the failure of heart to pump which is the intrinsic factor ( Thiele et al.,

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2015). The cardiogenic shock is manifested as increase or decrease in heart rate, increase in
respiratory rate followed by dyspnoea, decrease in blood pressure and increase in urine output
followed by oligouria. Initially there is an increase in temperature and then normal (Ostadal et
al., 2017).
Similar symptoms were observed in the case of Mr Frank where his blood pressure kept
decreasing after admission (from 156/98mmHg to 96/50mmHg). There was an increase in heart
rate from 124 to 128bpm. Respiratory rate was found to increase from 30bpm to 36bpm. The
patient temperature was 37°C and U/O 20mls/hr for the past 2 hours. The patient’s skin was
found to be sweating, and pale.
Using the ABCDE approach the chosen condition is discussed explaining the
pathophysiology of the signs and symptoms. ABCDE stands for Airway, Breathing, Circulation,
Disability and Exposure.
The patient’s airway assessment showed signs of cardiogenic shock- dyspnoea. The
assessment includes listening to the signs of airway obstruction. Pulmonary edema is caused by
the back flow, increasing the airway resistance which was the cause of “bat wings” in chest x
ray. The management includes ensuring that the airway is maintained. The aim of management
should be to increase the oxygen saturation to 99%. Pulmonary congestion and edema is caused
by the acute increase in the left arterial pressure. Oxygen can be given through facemask or
mechanical ventilation (Vital et al., 2013).Pulmonary edema leads to profuse sweating as
observed in patient.
Breathing assessment includes checking the rate and pattern, depth of respiration, colour
of patient, symmetry of chest movement and use of accessory muscles. In case of frank the

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underlying cause of low oxygen saturation, tachypnea, use of respiratory accessory muscles is
due to increased extraction of tissue oxygen as a result of low cardiac output. According to Diehl
(2017) lack of oxygen to heart destroys its left ventricle (pumping chamber). Left ventricular
function can be managed by administering the Lisinopril 10mgs PO mane (Burkhoff, 2015). The
heart muscles weaken due to poor oxygen-rich blood circulating to that area which progress into
shock. This is manifested as severe shortness of breath and rapid breathing. For the management
the patient is laid in flower position, as it will decrease the shortness of breath by reliving the
patient from pulmonary congestion. It may increase the venous return from the lower limbs and
reabsorption of peripheral edema (Chyrchel et al., 2015).
Circulation is assessed through manual pulse and blood pressure, fluid balance and urine
output, and temperature. The patient’s signs of cardiogenic shock showed weak pulse, low blood
pressure, raised jugular venous, decrease capillary refill time and arrhythmias. As the patient is
ischemic, his heart fails to generate adequate cardiac output. Systolic blood pressure due to
Peripheral vasodilation. It may also be caused due to systemic arteriolar shunting. Narrow
pulse pressure occurs due to reduced systolic BP and stroke volume. Generalised
vasoconstriction increases diastolic pressure. The underlying mechanism of decreased
urine output is the decreased renal perfusion (Levy et al., 2015). Administering the fluid may
restore the input and output balance.
Disability is assessed by pain score. Mr. Frank was found with altered level of
consciousness. Since cardiogenic shock occurs in patient with severe heart attack, the symptoms
of pain at the centre of chest that radiates back, beyond chest, to arms, and shoulders along with
nausea and vomiting is observed. Aspirin constitute the first line of treatment for initial
stabilisation. However, aspirin leads to nausea and vomiting as its side effects. It lowers the

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coagulation of blood and maintains normal flow through the constricted artery. Therefore, there
is a need to adjust dosage. Atenolol can treat the angina and elevating chest pain. It also helps
treats other complications of heart and blood vessels. Isosorbide mononitrate can also manage
the angina as prophylaxis but side effects include exacerbation of cardiogenic shock (Paudel et
al., 2016). All the three medicines results in side effects as confusion, head ache, vomiting and
nausea. To overcome the side effects the IV dopamine can be administered to increase cardiac
output and blood pressure (Kastrati et al., 2016).
Exposure related to complete examination from head to toe that in patient showed pale
cold and clammy skin. The skin of the patient with cardiogenic shock is initially flushed and
warm, which later turns cool and pale due to low blood supply. Restless and anxious state of
mind is observed during the cardiogenic shock. The confused state is related to arterial
hypoxemia and Cerebral hypoperfusion. Improvement in blood supply to brain can decrease
confusion. The side effect of Atenolol is confusion and cold extremities of hand, which was
observed in case of patient (Mebazaa et al., 2016). Further management includes monitoring the
vital signs and identify abnormal findings.
At this stage, nursing intervention can be positioning of patient in flower or upright
sitting position. The nurse can enhance safety and comfort by relieving pain and preventing
infection arterial and venous line insertion sites (Moorhead et al., 2014).
Part B
The clinical handover of the patient in shock is delivered in ISBAR format. ISBAR refers
to identifying the deteriorating patient, situation, background, assessment and recommendations.
Identify the client:

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 Mr Frank, 72 year old admitted to ward with an acute exacerbation of his chronic
heart failure
Situation:
 He is positioned in a semi-high fowler’s position
 He is mildly diaphoretic, mild shortness of breath, nausea
 Low blood pressure
 High score of chest pain
 Mental state-confusion
 BP 96/50mmHg, HR 128bpm, Resps 36bpm, U/O 20mls/hr for the past 2 hours
 ECG- reveals Q waves, ST depression and T wave inversion
 Chest x-ray reveals- diffuse infiltrates consistent with pulmonary oedema
Background:
 Mr. Frank has a history of stable angina for an undetermined period
 For the past 3 weeks, he has been experiencing pain radiating to his back every
hour
 sublingual nitroglycerin (GTN)- to relive radiating Pain
 Temperature- 37°C, Resps 30bpm, HR 124, BP 156/98mmHg
 Family history of cardiovascular disease- death of older brother from myocardial
infarction. His sister has had 3 MI’s
 Smoking history- 30 years
 Administered with Aspirin 7mgs PO mane, Atenolol 50mgs PO mane, Isosorbide
mononitrate 30mgs PO nocte, and Lisinopril 10mgs PO mane

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Assessment:
 Auscultate to detect heart sounds
 Electrocardiography- monitor MI, and ischemia
 Assess need of IV fluids
 Adjust the dosage of medicines to avoid side effects
 Maintain oxygen saturation between 88-92%
 Assess vital signs- blood pressure
 Monitor hemodynamic status
 Nursing intervention- prevent recurring of cardiogenic shock, administer
medication and intravenous fluids, enhance comfort and safety of patient
Recommendations:
 Smoking cessation as it exacerbates the cardiogenic shock symptoms (Rallidis &
Pavlakis, 2016)
 Adherence to treatment
 Diet should not be fat rich as it will increase the risk of stroke
 Follow up with nurse and physician for optimising treatment
 Healthy life style modification- physical activity, middle exercise

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References
Burkhoff, D. (2015). Device therapy: Where next in cardiogenic shock owing to
myocardial infarction?. Nature Reviews Cardiology, 12(7), 383-385.
Chyrchel, M., Dziewierz, A., Chyrchel, B., & Dudek, D. (2015). Images in intervention-
Transradial percutaneous coronary intervention for unprotected left main closure
during acute myocardial infarction. Postepy w Kardiologii Interwencyjnej, 11(2),
150.
Diehl, A. (2017). Ischaemic cardiogenic shock. Anaesthesia & Intensive Care Medicine.
Kastrati, A., Colleran, R., & Ndrepepa, G. (2016). Cardiogenic Shock.
Levy, B., Bastien, O., Bendjelid, K., Cariou, A., Chouihed, T., Combes, A., ... &
Spaulding, C. (2015). Experts’ recommendations for the management of adult
patients with cardiogenic shock. Annals of intensive care, 5(1), 17.
Mebazaa, A., Tolppanen, H., Mueller, C., Lassus, J., DiSomma, S., Baksyte, G., ... &
Masip, J. (2016). Acute heart failure and cardiogenic shock: a multidisciplinary
practical guidance. Intensive care medicine, 42(2), 147-163.
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Skalsky, I. (2017). P2774Long-term outcomes of patients treated with mini-

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invasive mechanical circulatory support for cardiogenic shock or refractory
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Rallidis, L. S., & Pavlakis, G. (2016). The fundamental importance of smoking cessation
in those with premature ST-segment elevation acute myocardial
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Thiele, H., Ohman, E. M., Desch, S., Eitel, I., & de Waha, S. (2015). Management of
cardiogenic shock. European heart journal, 36(20), 1223-1230.
Vital, F. M., Ladeira, M. T., & Atallah, Á. N. (2013). Non‐invasive positive pressure
ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. The
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