Chapter 6 Care of The Patient Experiencing Shock or Heart Failure

Understanding the
Essentials of
CRITICAL CARE Nursing
Chapter 6
Care of the Patient
Experiencing Shock or
Heart Failure
Copyright ©2009 by Pearson Education, Inc.

Understanding the Essentials of Critical Care Nursing Upper Saddle River, New Jersey 07458
Kathleen Ouimet Perrin All rights reserved.
Learning Outcome 1

Hypvolemia
• Results from decreased circulating volume

• Loss of 15–30 % or more of normal blood
volume

Etiology
• Hemorrhage
– GI bleed, trauma, surgery, ruptured aneurysm
• Fluid loss
– Vomiting, diarrhea, burns

Clinical Manifestations
• Hypotension
• Orthostatic
• Tachycardia
• Reduced capillary refill
• Dry mucous membranes
• Poor skin turgor

Clinical Manifestations (cont.)
• Thirst
• Weight loss
• Oliguria
• Concentrated urine
• Altered mental status

Diagnostic Criteria
• Reviews laboratory studies for:

– Hypernatremia (serum levels above 145
mEq/L)
– Increased hematocrit (Hct) due to
hemoconcentration (if patient actively
bleeding, Hct may drop)
– Arterial blood gases: metabolic acidosis
– Elevated serum lactate (serum lactate greater
than 4 mmol/L)
Diagnostic Criteria (cont.)
• Reviews laboratory studies for:

– Reduced mixed venous oxygen saturation
(SvO2 less than 60%; ScvO2 less than 70%)

Learning Outcome 2

Hypovolemic Shock
• In hypovolemic shock, the heart rate is

increased
• MAP, CVP/RA, and PAWP are decreased,
reflecting a reduced preload
• A reduction in circulating volume may also
lead to a reduction in SV and CO/CI
• An elevated SVR may be present,
reflecting the vasoconstriction due to
compensatory mechanisms
Learning Outcome 3

Collaborative Management Goals
• Early identification of hypovolemic shock is

the key to successful outcome
• Goal of treatment is to expand
intravascular volume
• Restore a normal circulating volume

Restoration of Volume
• Requires fluid challenges of an isotonic

solution through large bore intravenous
catheters
• Examples of isotonic crystalloid solutions
include 0.9% normal saline and lactated
Ringer’s solution

Restoration of Volume (cont.)
• These isotonic solutions are infused into

the vascular space and stay there long
enough to expand the intravascular space
• Fluid resuscitation starts with 1 to 2 liters of
crystalloid over 10 to15 minutes. Standard,
large (i.e., 14- to 16-gauge) peripheral IV
catheters or central venous catheters are
adequate for most fluid resuscitation

Restoration of Volume (cont.)
• The advantage of a central venous

catheter is that it can be used to monitor
CVP

Nursing Intervention
• Restore normovolemia and improve

cardiac output
• Fluid challenge of isotonic solution
• Monitor CVP readings
• Monitor calcium level
• Assess of respiratory compromise

Prevention and Detection of Life-
threatening Complications
• Renal insufficiency
• Cerebral ischemia
• Irreversible shock

Learning Outcome 4

Pathophysiology of Heart Failure
• As heart function fails and cardiac output

decreases, compensatory mechanisms
such as sympathetic nervous system and
renin-angiotensin-aldosterone system, are
activated
• The role of compensatory mechanisms is
to maintain perfusion to the vital organs

Pathophysiology of Heart Failure (cont.)
• Long-term activation of these mechanisms

can be deleterious, leading to:
– Increased afterload
– Pulmonary edema
– Peripheral edema
– Chamber dilation and/or hypertrophy—called
remodeling

Neurohormonal Mechanisms of Heart
Failure
• Primary mechanisms are sympathetic
nervous system
• Renin-angiotensin-aldosterone system
• Activation of sympathetic nervous system
releases norepinephrine = increased
vasoconstriction, heart rate, and
contractility
• Activation of renin-angiotensin-aldosterone
system stimulates aldosterone
Learning Outcome 5

Systolic vs. Diastolic HF
Systolic Diastolic
Impaired left ventricular Ventricle is normal size but
contractility hypertrophies
Reduced ejection Loss of left ventricular

fraction (normal 55–75%) diastolic relaxation
Decreased cardiac output Ejection fraction normal

Filling of ventricles impaired
PAWP is elevated
Learning Outcome 6

Clinical Manifestations of Heart Failure
• Manifestations occur depending on the

location of the failure
• Left-sided heart failure results in
respiratory manifestations
• Right-sided heart failure results in
peripheral manifestations

Clinical Manifestations of Heart Failure
(cont.)
Left-sided Right-Sided
Manifestations Manifestations
Dyspnea on exertion Peripheral edema
Orthopnea Abdominal pain and
distention
Paroxymal noctural Weight gain
dyspnea
Crackles on Ascites
pulmonary auscultation Jugular vein distention

End Organ Hypoperfusion Is
Manifested By:
Decreased exercise Fatigue
tolerance
Dizziness Syncope
Palpitations Hypotension
Tachycardia Cool extremities
Delayed capillary refill Decreased urinary
output

Learning Outcome 7

Hemodynamic Findings
• Nurse monitors for trends indicating

volume overload or decompensation
• Elevated filling pressures may be elevated
in heart failure
• RA/CVP (right filling pressures) is elevated
= peripheral edema

Hemodynamic Findings (cont.)
• PAWP (left filling pressures) is elevated =

pulmonary edema
• Cardiac output normal
• Elevated systemic and pulmonary vascular
resistance

Diagnostic/Laboratory Tests
• Laboratory Tests
– Sodium
– BUN and creatinine
– B-type natriuretic peptide
• Diagnostic Tests
– Chest x-ray
– ECG
– Noninvasive cardiac tests
– Invasive cardiac tests
Learning Outcome 8

Contrasted Hemodynamic Findings of
Heart Failure and Hypovolemia
Heart Failure Hypovolemia
RA/CVP is elevated RA/CVP is decreased
PAWP is elevated MAP is decreased
Cardiac output normal CO/CI is reduced
Elevated systemic and SV reduced
pulmonary vascular
resistance

Learning Outcome 9

Collaborative Management
• Nurse works with MD to manage

symptoms
• Reduce the progression
• Prolong survival
• Pharmacological and nonpharmacologic
measures

Nurse Management/Interventions
• Administer medications as ordered

– Ace inhibitors
– Beta blockers
– Aldosterone antagonists
• Monitor for side effects of ace inhibitors
– Dizziness
– Hypotension
– Cough
– Hyperkalemia
(cont.)
• Monitor for fluid volume excess
– Administer diuretics
– Monitor intake and output
– Assess respiratory status
• Monitor for impaired gas exchange
• Monitor for decreased cardiac output
– Vasodilators
– Inotropes
– Digoxin
(cont.)
• Monitor for complications and
interventions
– Dysrhythmias
– Pulmonary edema
– Hypercarbia
– Cardiogenic shock

Common Medications Used for
Complications
• Venodilators
– Morphine sulfate
– Nitroglycerin
• Vasodilators
– Nesiritide (Natrecor)
• Intravenous inotropics
– Dobutamine
– Milrinone
Learning Outcome 10

Acute Decompensated Heart Failure
(Cardiogenic Shock)
• Prevention is linked to early detection and
appropriate management
• Patient compliance with lifestyle
modifications may decrease occurrence
• Appropriate nurse assessment is crucial

Nurse Assessment of Decompensated
Heart Failure
• Dyspnea at rest
• Tachycardia
• Reduced oxygen saturation
• Crackles on lung auscultation
• Hypotension
• Worsening cough
• New dysrhythmias
• Elevation of PAWP
• Reduction in CO/CI
Learning Outcome 11

Collaborative Management of Acute
Decompensated Heart Failure
• Oxygen therapy of 100% nonrebreathing
mask
• BIPAP may be appropriate

Nursing Management
• Assess for complications from CPAP or

BIPAP
– Air leak around the mask
– Facial skin breakdown
– Gastric distention
– Vomiting and aspiration
– Claustrophobia

Pharmacological Interventions
• Venodilators (morphine and nitroglycerin)
• Venodilators reduce preload and PAWP
• Morphine sulfate reduces anxiety and
venodilate
• Nurse must assess for side effects/adverse
reactions of morphine
– Excessive decrease in respiratory rate
– Excessive decrease in oxygen saturation
– Hypotension
– Decreased level of consciousness

Nitroglycerin
• Clients who do not respond to morphine

may be treated with nitroglycerin
• Nitroglycerin Administration
– Special tubing to prevent excessive absorption
of the drug
– Assess blood pressure, heart rate, respiratory
rate, and oxygen saturation
– Assess for side effects: hypotension,
tachycardia, headache
Other Pharmacological Interventions
• Nesiritide (Natrecor) given IV

– Does not increase heart rate
– Cannot replace diuretics
– Closely monitor the blood pressure
• Intravenous inotropic therapy
– Clients who remain in pulmonary edema
– Dobutamine and milrinone (Primacor)
• Increase dose of diuretics (IV)
Signs of Cardiogenic Shock
• Cardiac index < 2.0 L/min

• Systolic blood pressure less than 90
mmHg
• PAWP above 19 mm Hg
• Intraaortic balloon pump may be used


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Chapter 6 Care of The Patient Experiencing Shock or Heart Failure

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Verfügbare Formate

Understanding the

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

• Results from decreased circulating volume

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

• Reviews laboratory studies for:

• Reviews laboratory studies for:

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

• In hypovolemic shock, the heart rate is

Copyright ©2009 by Pearson Education, Inc.

• Early identification of hypovolemic shock is

Copyright ©2009 by Pearson Education, Inc.

• Requires fluid challenges of an isotonic

Copyright ©2009 by Pearson Education, Inc.

• These isotonic solutions are infused into

Copyright ©2009 by Pearson Education, Inc.

• The advantage of a central venous

Copyright ©2009 by Pearson Education, Inc.

• Restore normovolemia and improve

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

• As heart function fails and cardiac output

Copyright ©2009 by Pearson Education, Inc.

• Long-term activation of these mechanisms

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

Reduced ejection Loss of left ventricular

Decreased cardiac output Ejection fraction normal

Copyright ©2009 by Pearson Education, Inc.

• Manifestations occur depending on the

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

• Nurse monitors for trends indicating

Copyright ©2009 by Pearson Education, Inc.

• PAWP (left filling pressures) is elevated =

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

• Nurse works with MD to manage

Copyright ©2009 by Pearson Education, Inc.

• Administer medications as ordered

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

• Assess for complications from CPAP or

Copyright ©2009 by Pearson Education, Inc.

Copyright ©2009 by Pearson Education, Inc.

• Clients who do not respond to morphine

• Nesiritide (Natrecor) given IV

• Cardiac index < 2.0 L/min

Copyright ©2009 by Pearson Education, Inc.

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