Acute Care Cardiogenic Shock Case

L.V. is a 68-year-old male admitted to the coronary care unit 24 hours ago with an anteroseptal myocardial infarction (Mi). His past medical history includes two other Mis within the last 5 years, obesity, hypertension, hyperlipidemia, and sleep apnea. L.V. had chest pain at home for 12 hours before seeking medical treatment. Lab results note troponin I at 5.2 ng/mL, creatine kinase (CK) at 1202 U/L, and CK-MB at 8.2%. L.V. is currently pain free with stable VS. The cardiac monitor shows sinus rhythm with occasional, unifocal premature ventricular contractions and a heart rate (HR) in the 90s. His blood pressure (BP) is 130/70, respiratory rate (RR) is 24 breaths/minute and 02 saturation is 93% on 02 via nasal cannula at 2 L/min. He has a heparin drip infusing at 1200 U/hr and IV nitroglycerin infusing at 20 mcg/min. You are assigned to care for L.V. as part of a three-patient assignment. 1. Cardiogenic shock can result from a variety of initiating events. In addition to L.V.'s obvious myocardial infarctions, identify other potential contributing causes that you will assess in L.V. There are five correct answers. Internal bleeding Aortic dissection Cardiac tamponade Valvular disorders Cardiomyopathy Infection Severe systemic or pulmonary hypertension Allergies Dysrhythmias 2. After receiving report from the night shift, you are assigned to care for three different patients including (1) L.V., (2) a 42-year-old patient with unstable angina on a nitroglycerin drip who is pain free, and (3) a 54-year-old female who is 1-day post-angioplasty and will be transferred to the step-down unit later this morning. Prioritize your initial assessments by numbering the patients according to who should be seen first, second, and third. Group of answer choices 1 [ Choose] Post-angioplasty Unstable angina Myocardial Infarction [ Choose] Post-angioplasty Unstable angina Myocardial Infarction [Choose] Post-angioplasty Unstable angina Myocardial Infarction 3. During assessment of L.V., you find him to be apprehensive and slightly restless but oriented to person, place, and time. Vital signs are as follows: BP 110/60, HR 110 beats/minute, RR 28 breaths/minute, temperature 36.4° C (97.5° F). Lung sounds reveal fine bibasilar crackles. His abdomen is soft with hypoactive bowel sounds. He has not voided since midnight. His skin is pale and cool. Knowing that he is at risk for cardiogenic shock, you realize that these assessment findings may correlate with which stage of shock? Compensatory Progressive Irreversible 4. You notify the health care provider regarding the assessment findings and concerns noted in the previous question. The health care provider states that he will do rounds on his patients shortly and asks that you monitor L.V. closely. Being an astute critical care nurse, you know the importance of identifying minor changes that may signal a worsening condition in the patient. As you monitor L.V. for potential deterioration into the progressive stage of cardiogenic shock, select the clinical manifestations that would alert you to this occurrence. There are 12 correct answers. Increased crackles Thrombocytopenia Listlessness Polyuria Dysrhythmias Bleeding Decreased urine output Decreased temperature Decreased liver enzymes Increased urine osmolality Increased blood urea nitrogen (BUN) Decrease blood pressure Metabolic alkalosis Anasarca Jaundice Decreased level of consciousness 5. Unfortunately, L.V. quickly begins to deteriorate and displays symptoms of progressive cardiogenic shock. His BP is 84/50, HR 132, RR 30, temperature 96.8° F (36° C), and oxygen saturation 89% in spite of supplemental oxygen. As his health care provider is notified, which interventions should you be prepared to initiate? There are seven correct answers. Furosemide 40 mg IV STAT Atropine 0.5 mg IV push now Titrate 02 to pulse oximetry greater than or equal to 90% Infuse a 500 mL IV bolus of normal saline Nipride IV at 20 mcg/kg/min Discontinue nitroglycerin until systolic blood pressure greater than 90 Arterial blood gases (ABGs) STAT Dopamine IV at 5 mcg/kg/min Dobutamine IV at 10 mcg/kg/min Adenosine 6 mg IV push STAT, may repeat with 12 mg bolus in 5 min x 2?????? 12-lead ECG 6. The health care provider orders L.V. to receive IV dopamine at 5 mcg/kg/min along with IV dobutamine at 10 mcg/kg/min. As you prepare to administer dopamine, the following is available: dopamine 400 mg in 500 mL DSW. L.V. weighs 242 lb. How fast will you infuse this IV using an IV infusion pump? 60.5 mL/hr 5 mL/hr 41.3 mL/hr 25 ml/hr 7. Next you prepare to administer dobutamine. The following is available: dobutamine 250 mg in 250 mL D5W. How fast will you infuse this IV using an IV infusion pump? Group of answer choices 10 ml/hr 15 ml/hr 34 mUhr 66 mL/hr 8. As you start the ordered IV infusions, L.V.'s health care provider arrives and decides to insert a pulmonary artery (PA) flow-directed catheter and an arterial line. Identify the nursing responsibilities in preparing for these procedures. There are four correct statements. Zero reference the transducers. Assess L.V's most recent serum electrolytes and coagulation profiles Administer 5000 units IV heparin to prevent clotting of the lines Prime and pressurize the flush tubing for both the PA and the arterial catheter. Notify anesthesia for needed sedation Have patient sign consent form. Place L.V. in side-lying position. 9. After insertion of the pulmonary artery and arterial lines, you are careful to place the zero reference stopcock at the phlebostatic axis. The phlebostatic axis is defined as the intersection of two imaginary lines: one drawn horizontally from the axilla, midway between the anterior and posterior chest walls, and the other drawn vertically through the along the lateral chest wall. Third ICS Fourth ICS Second ICS Fifth ICS 10. After proper positioning and set-up of the PA and arterial lines, you obtain the following readings: pulmonary artery systolic pressure/pulmonary artery diastolic pressure (PASP/PADP) 16/4 mm Hg. pulmonary artery wedge pressure (PAWP) 5 mm Hg, cardiac output (CO) 3.2 L/min, cardiac index (CI) 2.0 L/min, and BP 80/40 mm Hg. At this point, which additional intervention would you expect the health care provider to order? Normal saline solution 500 mL IV bolus now Lasix 80 mg IV STAT Decrease dobutamine to 5 mcg/kg/min Restart nitroglycerin at 10 mcg/min 11. In order to facilitate best care for all three patients, you understand the need to delegate to unlicensed assistive personnel (UAP). Which activities would be appropriate to ask the UAP to complete? (Select all that apply.) Obtain blood from L.V.'s arterial line for ordered lab tests Zero reference and flush the hemodynamic lines q4hr Measure and document L.V.'s intake and output Provide frequent oral and skin care Obtain sterile urine sample from catheter. 12. L.V. does respond to the NSS bolus. As you continue to monitor him, which of the following changes would indicate a therapeutic response specific to the dobutamine infusion? Increased systolic BP Increased CO Increased SVR Increased PAWP 13. You take a moment to call report to the step-down unit on A.L., your 54-year-old patient, in preparation for transfer. Match each component of the SBAR communication technique with the corresponding report statement. "A.L. is a 54-year old patient who is 1-day postangioplasty of her right coronary artery." Background Recommendation Situation [Choose] Assessment "A.L. is chest pain free and her right groin is slightly ecchymotic with no hematoma or bruit noted. Normal sinus rhythm on the monitor." [Choose) Background Recommendation Situation Assessment "A.L. came to the ED yesterday with intermittent chest pain and underwent a cardiac catheterization. She has no previous cardiac history." [ Choose ] Background Recommendation Situation Assessment "A.L. was given education regarding oral anticoagulation but she could use reinforcement of this information, specifically related to dietary implications." [ Choose ] Background Recommendation Situation Assessment 14. Three hours later L.V.'s condition continues to deteriorate. He now displays a decreased level of consciousness (LOC), decreased urine output, and respiratory dysfunction. STAT ABGs are drawn and L.V. is intubated and placed on a ventilator. Which ABG result is most consistent with this scenario? Group of answer choices pH 7.52, PaCO2 35, Pa02 68, HCO3 25 pH 7.28, PaCO2 55, Pa02 60. HCO3 25? pH 7.35, PaCO2 45, Pa02 80, HCO3 25 pH 7.45, PaCO2 45, Pa02 90, НСО3 25?| 15. The health care provider also decides to insert an intra-aortic balloon pump (IABP) to provide circulatory assistance to L.V.'s injured myocardium, giving it time to recover. Proper programming of this pump will have the balloon inflate at the start of diastole and deflate just before systole . The therapeutic effect of the IABP is to reduce afterload and increase coronary artery perfusion. Options: Afterload Diastole Perfusion Preload Pressure Systole 16. Because of superb medical and nursing care, L.V. survives the acute phase of cardiogenic shock. He is gradually weaned off the IABP, hemodynamic medications, and ventilator over a period of 10 days. At this point, what needs would you anticipate for L.V.? There are four correct responses. Discussion with heath care provider regarding strategies to prevent recurrent cardiogenic shock, such as cardiac resynchronization therapy or heart transplant. Occupational therapy to regain ability to perform normal activities of daily living Dietary consult for high-carbohydrate and high-fat diet to regain lost weight Home health care nurses to monitor medical status and provide instructions to prevent recurrent MI Physical therapy to regain strength and endurance L.V. receives daily physical and occupational therapy in addition to extensive patient teaching regarding his disease process, medications, and dietary needs. Seven days after being transferred to a step-down unit from intensive care, L.V. is discharged to an acute rehabilitation facility for further conditioning before going home.