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Shelley Hart Alverno College- MSN 621

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1 Shelley Hart Alverno College- MSN 621

2  Click on any underlined words for an in depth explanation  Use the arrows at the bottom of the page to move around the tutorial  Use this arrow to move forward :  Use this arrow to move backward :  Use this button to return to the beginning of the show:

3 Understand the pathophysiology of cardiogenic shock Explain the compensatory mechanism for low oxygenation to the tissues Identify the what you see as signs and symptoms of cardiogenic shock Identify the nursing interventions for the assessment and management of cardiogenic shock

4 Would you like to learn more about the physiology of the heart? Click here for a heart link : Usually there is a myocardial injury and a loss of contractility of the heart Then the heart is unable to provide enough oxygen to the body resulting in poor tissue perfusion to the major organs ysystem/heart/menu/menu.html Sheffield, 2008

5  Why? ◦ Impaired blood flow to the coronary arteries  How does this look? ◦ Blood flow is blocked either by a clot or plaque in various degrees, so part of the artery is blocked or most of it is blocked ◦ ECG will show changes T wave inversion, ST segment elevation or abnormal Q wave ECG  When can you diagnose this problem ? ◦ Timing of serum cardiac marker elevationserum cardiac marker Porth,2005,p.539

6 ST wave elevation -First changes seen -Abrupt onset and chest pain -Signal that heart muscle is damaged Abnormal Q wave -No depolarizing -necrotic /damaged heart tissue -change in conduction ST Normal ECG waveform Q wave 1 mm T wave T –wave inversion -disruption in repolarization -may be earliest sign of Myocardial injury Adapted from: ER Club of NYU School of Medicine,2007.

7  Enzymes within the markers located in the heart muscle breakdown and are released during heart damage  They are seen in blood within certain times frames of a heart attack or also called MI: ◦ Myoglobin- within 1 hour ◦ Creatine-kinase MB ( CK-MB)- within 4-8 Hours ◦ Troponin I- within 3 hours ◦ Troponin T- within 3 hours

8  If a patient enters with chest pain and ECG changes that show a ST elevation. You may need to review lab results called…  A) coag panel A) coag panel  B) serum cardiac markers B) serum cardiac markers  C) UA and culture C) UA and culture  D) CBC with diff D) CBC with diff  The earliest blood test that may show cardiac damage would be  A) troponin I A) troponin I  B) troponin T B) troponin T  C) myoglobin C) myoglobin  D) CK- MB D) CK- MB Let’s move on to compensation

9 Cool Right Answer Microsoftclipart,2008 Move on to Compensation

10 These are important tests but would NOT be urgent for a cardiac problem,go back please…

11 Chest pain indicates a cardiac problem rather than a clotting problem. A coag panel determines a clotting time Think cardiac to cardiac enzymes..go back Microsoftclipart.com2008

12 This test takes a long time to peak in the blood, a cardiac problem is urgent,need information in minutes Rethink this.. Microsoftclipart.com2008

13 Compensatory Mechanisms  OK we know the cause of the problem now to the next part of the problem..  In the beginning of shock, the tissues are not receiving enough oxygen because there is less blood flow to the organs  How does the body try to restore blood flow to the major organs? Inflammatory RAA SNS

14 Kidney  The kidney plays a big role in the function of the blood pressure  Special enzymes are secreted to help the blood pressure from going too high or too low. This is important in cardiogenic shock.,2008

15 Blood Pressure  Remember the heart is not pumping normally, so the blood vessels are not working properly and the blood pressure decreases.  An enzyme called Renin is secreted from the kidney  Renin secretion sets a pathway into motion  Vasoconstriction is a result of this pathway  And Vasoconstriction causes a slight rise in the blood pressure Renin BP

16 Third step 4 th step Next? Result First the blood pressure falls Second, Renin is released from the kidneys Renin reacts with the protein, Angiotensinogen Angiotensin I is formed Angiotensin Converting Enzyme (ACE) from the lungs converts… Angiotensin II is a product of the conversion and causes… Vasoconstriction, Move on to see how aldosterone impacts this picture,2008

17 Aldosterone flips on the switch for the sodium and potassium pump. Angiotensin II stimulates the release of aldosterone from the adrenal cortex Aldosterone is released Kidneys conserve sodium Kidneys conserve water Na+/ K+ Pump switch is ON Thus the blood pressure increases Blood volume increases

18 Then what happens? SNS causes vasoconstriction Then the heart rate increases The heart contraction is stronger BUT in this situation the heart is weakened from the cardiac event The ventricles cannot pump effectively and overfill with blood

19 Alpha and beta adrenergic receptors Body Alpha receptors are on blood vessels,skin and eyes and start to affect their normal function AND Beta adrenergic receptors start to affect the heart, lungs, and other tissues Microsoftclipart,2008

20  Where are the alpha and beta receptors that cause vasoconstriction and cause excitation?  Click on alpha or beta to match the affected organ alpha beta eyes Blood vessel heart lungs Microsoftclipart,2008

21  What organ is involved with renin secretion?  A. heart A. heart  B. lungs B. lungs  C. kidney C. kidney  D. brain D. brain  The body compensates for decreased tissue perfusion by :  A. Decreasing the heart rate A. Decreasing the heart rate  B. Vasoconstriction B. Vasoconstriction  C. Vasodilation C. Vasodilation  D. Decreasing the blood pressure D. Decreasing the blood pressure Move on to inflammation

22 Hooray you are correct!! Move on to inflammation

23 The lungs do host the angiotensin converting enzyme but does not secrete renin Close but this is incorrect

24 The brain is not involved directly with renin secretion No…. this answer is incorrect

25 The heart does not secrete renin Choose another answer

26 Leukocytes are alerted !!Cytokines are released!!  Living cells in the tissue are injured without oxygen  This cardiac event is preventing oxygen from getting to the tissues  Cytokines are released Alert Injury !! Sheffield,2008

27 Cytokine  A cytokine is an inflammatory mediator that communicates with other cells important to the inflammatory response  Some bind to the cell surface receptors and trigger release of more cytokines and nitric oxide (NO)  Nitric oxide is a strong vasodilator Attention all neutrophils, I need assistance at this point of injury ! Microsoftclipart,2008

28 TNF Genetic connection in survival  Tumor Necrosis Factor ( TNF) is an inflammatory mediator and one of the cytokines in the inflammatory process  People that have a genetic TNF-2 allele, may survive cardiogenic shock at a better rate than patients without the allele or people with TNF 1 allele  Interestingly enough the opposite has been observed in patients with septic shock Microsoftclipart,2008

29 Leukocytes ActionEndothelium Action  Leukocytes make integrins  Integrins help leukocytes bind to the endothelium  Just as leukocytes are making integrins  The endothelium is making integrin receptors and selectins  The cytokines will activate the integrins to attach to the receptors

30 What is happening? Picture the cytokine action and leukocyte effect The endothelium has the leukocytes sticking to it Cytokines are releasing nitric oxide causing vasodilation

31 Sticky endothelium and pooling of blood products  Pooling of blood and slowing of blood flow through the capillaries  Increased permeability and leaking of fluid into interstitial space  Platelets and leukocytes stick and clog up the endothelial wall Leukocytes Platelets Interstitial leakage

32  The end result of the inflammatory response in cardiogenic shock is:  A) leaky vessels A) leaky vessels  B) decreased oxygen to the major organs B) decreased oxygen to the major organs  C) Cytokine secretion C) Cytokine secretion  D) Endothelium Changes D) Endothelium Changes,2008

33 Your answer is part of the inflammatory response but it’s earlier in the events of the total result to the body Try again

34 Hooray your answer is correct !!! Move on to patient care

35 May develop hours after the initial MI is detected Who is at risk for cardiogenic shock?  Patient 65 years or older  High blood pressure  Diabetes  Obesity  Those who smoke  Hyperdyslipidemia  Frequency ◦ 8.6% of patients with a ST elevation MI Microsoftclipart,2008

36 What will you see, hear and feel from the patient? Chest Pain Suggests a myocardial infarct

37 Defining symptomsAssessment  Minimally you will see: ◦ Cool extremities ◦ Decreased urine output ◦ And most importantly a low blood pressure with systolic <90 mmHg Microsoftclipart,2008,2008

38 Signs and symptoms  Produce these signs and symptoms: ◦ Rapid pulse ◦ Narrow pulse pressure ◦ Distended neck veins  Right ventricular failure ◦ Arrhythmias ◦ Decreased mentation ◦ Dyspnea ◦ Elevated respiratory rate ◦ Inspiratory crackles, wheezing  Left ventricular failure ◦ Absent bowel sounds Microsoftclipart,2008

39  Mr. CP is a 55 year old man that enters the emergency room complaining of cramping abdominal pain and chest pressure as well as nausea. He is cool and clammy to the touch. He states he cannot remember his phone number and he feels scared about this feeling of pain in chest.  The main defining symptoms of a cardiac injury and possibly cardiogenic shock would include:  A) chest pain A) chest pain  B) chest pain, cool and clammy skin B) chest pain, cool and clammy skin  C) confusion C) confusion  D) chest pain and confusion D) chest pain and confusion Move on to lab values

40 Excellent you are right !! Move on to lab values

41 These are signs and symptoms but there are two issues that this patient complains of pinpoint cardiac problems No try again…

42 Chest pain is the main cardinal sign of a cardiac problem and this patient also exhibited something else This isn’t exactly correct….

43 Lab ValuesAssessment  Elevated myocardial tissue markers ◦ Elevated myocardial bands of creatinine phophokinase( MK-CPK) ◦ Elevated Troponin I ◦ Elevated BNP-Brain Natriuretic Peptide  Arterial Blood Gases ◦ Decreased PaO 2  C Reactive Protein  Hemodynamic values Microsoftclipart,2008

44 What will the physician order?  Narcotics  IV fluids  Arterial Line  Central Line  Electrolyte replacement ◦ K+, Calcium, Mg+  ECG, Cardiac monitor ◦ Cardioversion ◦ Pacing  Possible Diuretics  Antidysrhythmic drugs  Vasodilators  Narcotics  Procedures Procedures Microsoftclipart,2008

45  Immediate revascularization is necessary to restore oxygen to the heart muscle and then support oxygen delivery to the rest of the body  Intra-Aortic Balloon Pump (IABP) used as a bridge until revascular efforts are completed  Coronary Artery Bypass Graft (CABG)  Percutaneous Coronary Intervention (PCI)

46  Mr. CP is a 55 year old man that enters the emergency room complaining of cramping abdominal pain and chest pressure as well as nausea. He is cool and clammy to the touch. He states he cannot remember his phone number and he feels scared about this feeling of pain in chest.  You take his vital signs and determine that his blood pressure is 80/50 and his heart rate is 96. While you call the physician and other staff to assist you with this patient…  What will you expect the physician to order immediately:  A) Blood cultures A) Blood cultures  B) ECG, IV fluids, Oxygen support B) ECG, IV fluids, Oxygen support  C ) Antihistamine C ) Antihistamine  D) Abdominal x- rays D) Abdominal x- rays Go to next case study

47 The suspected shock is cardiogenic with the hallmark sign of chest pain, life saving measures need to start after the initial assessment Super … right selection Go to next case study

48 Remember that chest pain and symptoms of decreased cardiac output would need interventions that would increase vasodilation and increase oxygen Unfortunately that is incorrect Let’s rethink that response

49 Let’s try to see the whole picture using the nursing process…

50 ProblemWhat you know so far…  Chester Pain is your patient returning from the cardiac cath lab until the cardiac surgical team arrives. The cardiologist noticed several blockages but he was unable to advance the guide wire.  The cardiothoracic team is coming in to perform an emergency bypass surgery. In the meantime..  You will need to monitor and intervene on the cardiac unit until the surgical team arrives…  Chester’s B/P is 80/50, pulse is 115. He is also diaphoretic, weak pulses, low urine output, mild confusion and some agitation

51 Medical Procedures for Monitoring Purposes  The cardiologist placed an Intra arterial balloon pump for increased myocardial perfusion.  He also placed pulmonary arterial catheter and arterial line.  Chester has a foley catheter in place Microsoft clipart,2008

52 MonitoringEquipment  Monitor for changes in ◦ Level of consciousness ◦ Heart rate ◦ Blood pressure ◦ ( Low B/P can lead to further organ damage) ◦ SpO2 ◦ Breath sounds ◦ Urine output ◦ Pain and anxiety Microsoft clipart,2008

53 Assessment Intervention and Evaluation Critical Thinking  Administer medications ◦ Adjust per lab and monitor interpretation Diuretics Vasopressors ( lo B/P) Dobutamine, S>80 Dopamine, S<80 Norepinephrine Vasodilators Nitroglycerin  Oxygenation ◦ Possible monitor of mechanical ventilation Is there fluid overload ? Should I adjust the IV fluids? Microsoftclipart,2008

54  Assess fluid overload by labs and these signs and symptoms: ◦ Frothy secretions ◦ Decreased oxygen saturation ◦ Crackles  Values that are important: ◦ Decreased B/P ◦ Narrow pulse pressure ◦ Cardiac index < 2.1 l/min/m2 ◦ Pulmonary artery wedge pressure > 20mmHG ( normal is 8-12 mmHg) ◦ Central venous pressure ( normal is 2-6 mm Hg.)

55 ASSESSInterpret and Intervene  He is somewhat short of breath, mild chest pain and anxious about surgery.  His lung sounds reveal slight crackles in the bases  His wedge pressure is 22, CVP is 12 and his urine output is still low  You reassure the patient that his family is aware of the situation. The cardiac team is here and he is going in for surgery in 15 min.  You start a dobutamine drip at 5 mcg/min/kg IV and dopamine 5 mcg/min/kg IV. Plus he still on a heparin drip.  You give him 1 mg morphine IV for pain and anxiety.

56 EvaluationFurther treatment  The cardiac team arrives  You give report that Chester is less anxious,pain free at this time  He still has increased urine output but it is still low. You have not increased his amount of fluid per hour.  He still has crackles in his lungs  Further labs are drawn and the cardiac enzymes are still elevated, the BUN and creat are elevated  You send Chester off to the operating room where he has a successful by pass of 4 arteries.  You later learn that he went home 5 days later.

57  Monitoring and correcting low blood pressure with vasopressors is important to :  A) prevent organ damage A) prevent organ damage  B) Keep patients comfortable B) Keep patients comfortable  C) correct breathing problems C) correct breathing problems  D) increase the oxygenation D) increase the oxygenation  Fluid overload may be characterized by:  A) pain A) pain  B) decreased blood pressure, low urine output B) decreased blood pressure, low urine output  C) Lung assessment that includes crackles, low B/P,low urine output C) Lung assessment that includes crackles, low B/P,low urine output  D) hypertension with wide pulse pressure D) hypertension with wide pulse pressure Last slide

58 This is a good answer. All of the organs have to function for the best patient outcome. Celebrate !!

59 Breathing will not improve from vasopressors. The action of the medication will increase the blood pressure and return oxygen perfusion to the tissues Incorrect

60 Oxygenation may improve from better tissue perfusion to the organs so this isn’t the total outcome Pick another answer…

61 Pain is not affected by vasopressors or increasing the blood pressure Go back and try again

62 You need assessment skills plus the medical information to intervene properly Great !! Last slide

63 The blood pressure and urine output may be a problem of a result of organ damage or increased heart damage Sorry Not the answer

64 Pain is indicative of an advancing cardiac event Sorry Not the answer

65 Hypertension and wide pulse pressure is the opposite of what the body would do during fluid overload in this case Sorry Not the answer

66  You are finished!! Microsoftclipart.com2008

67  Appolini, O., Dupont, E., Vandercruys, M., Andrien, M., Duchateau, J., & Vincent, J. (2004). Association between the TNF-2 Allele and a Better Survival in Cardiogenic shock. Chest, 125(6), 2232-2237.  Brandler, E., & Sinert, R. (2008, Apr. 2). eMedicine - Shock, Cardiogenic : Article by Ethan S Brandler. Retrieved Apr. 14, 2008, from  Feldman, H., & Rey, M. (n.d.). Learning EKG interpretation. Retrieved Apr. 11, 2008, from  Morton, P., Fontaine, D., Hudak, C., & Gallo, B. (2005). Critical Care Nursing : A holistic approach, 8th edition. Philadelphia, PA: Lippincott,Williams & Wilkins.  Mower -Wade, D., Bartley, M., & Chiari-Allwein, J. (2000). Shock Do you know how to respond?. Nursing 2000, 30(10), 34-39.  Sheffield, S. (2008, Apr. 14). GetBodySmart: Interactive Tutorials and Quizzes On Human Anatomy and Physiology. Retrieved Apr. 14, 2008, from  Weil, M. (n.d.). Shock: Shock and fluid resuscitation: Merck Manual Professional. Retrieved Apr. 14, 2008, from

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