Question:

Answer:

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., 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 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 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:

• 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:

• 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

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

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.

Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2014). Nursing Outcomes Classification (NOC)-E-Book: Measurement of Health Outcomes. Elsevier Health Sciences.

Ostadal, P., Kruger, A., Vondrakova, D., Janotka, M., Mates, M., Kmonicek, P., … & Skalsky, I. (2017). P2774Long-term outcomes of patients treated with mini-invasive mechanical circulatory support for cardiogenic shock or refractory cardiac arrest. European Heart Journal, 38(suppl_1).

Paudel, R., Beridze, N., Aronow, W. S., Ahn, C., Sanaani, A., Agarwal, P., … & Panza, J. A. (2016). Association of chest pain versus dyspnea as presenting symptom for coronary angiography with demographics, coronary anatomy, and 2-year mortality. Archives of medical science: AMS, 12(4), 742.

Rallidis, L. S., & Pavlakis, G. (2016). The fundamental importance of smoking cessation in those with premature ST-segment elevation acute myocardial infarction. Current opinion in cardiology, 31(5), 531-536.

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 Cochrane Library.