Cardiogenic shock is a cardiovascular condition characterized by the inability of the heart to pump oxygen-rich blood to vital organs. Most commonly caused by an acute myocardial infarction, cardiogenic shock is an emergency that requires immediate treatment to restore blood flow (NHLBI, n.d.). Management of cardiogenic shock is complex as impaired myocardial performance results in diminished cardiac output, end-organ hypoperfusion, and hypoxia (Vahdatpour et al., 2019). John Clements is a 71-year-old male patient who recently had a triple vessel coronary artery bypass after an anterior wall myocardial infarction. Medical history shows hypercholesterolemia and hypertension, however physical examination demonstrates hypotension (90/46mmHG).
The patient history identifies COPD which explains the gradual decrease to SpO2 levels from a normal 95% to 88%, indicative of hypoxemia alongside tachypnea (respiratory rate: 29). Physical examination demonstrates grade 2 edema and bluish phalanges indicative of disruptive blood flow. An ECG presents a slow atrial fibrillation with ST segment depression, with crackles audible on auscultation of the lung fields. It is evident that the patient is experiencing deterioration with two symptoms to examine are hypotension and hypoxemia. Using a case study approach after the identification of clinical deterioration, the priority problem of decreased cardiac output related to cardiogenic shock is identified and justified. The paper will explore the causes of failing to recognize deterioration and providing evidence-based interventions on responding to the patient at hand in order to stabilize his condition and reduce the risk of further cardiogenic or secondary complications.
Failure to Recognize Deterioration
Severe adverse events, such as cardiogenic shock or even unexpected death are preceded by observable physiological, clinical, and mental health abnormalities. A myriad of factors can contribute to lack of early identification or response to acute deterioration, but the most relevant for this case is “Not monitoring physiological observations consistently, or not understanding changes in physiological observations” (Australian Commission on Safety and Quality in Health Care, 2020). Some of the indicators of this in the case study include: the allocated nurse to a patient that is in critical recovery is not present during morning assessment. Vital signs such as blood pressure were either not collected or recorded through the night, thus challenging to identify dynamic. Despite early indicators of hypoxemia alongside tachypnea in the patient, no action was taken.
A systemic review of studies indicates the median incidence of adverse events in hospitals across Anglo-Saxon countries is a 9.2%, with approximately half regarded as preventable (de Vries et al., 2008). The pivotal role falls to nurses that are able to recognize and respond to indicators of patient deterioration in a timely manner. A 17-study analysis by Massey et al. (2016) identifies four primary themes in recognizing patient deterioration. Assessing the patient was critical as vital signs and observations are quantifiable and trackable indicators – if critical vital signs are not tracked appropriately, identifying deterioration and subsequent decision-making process can be challenging. Knowing the patient is necessary, with nurses who lacked awareness of the medical history or not familiar with the status could lead to lesser recognition of deterioration. Clinical education and skills training are imperative to recognizing deterioration, with ward nurses with a lower level of education or less clinical experience were less confident in this aspect. Equipment may also play a role in some cases as automated machinery can both, track vital signs, but also create overreliance from medical staff, decreasing holistic assessment that results in poor recognition of deterioration (Massey et al., 2016).
A number of environmental factors can affect the recognition and response to deteriorating patients. Elements such as physical planning of the facility, staff workflow and rotations, and integration of technology can be influential factors. The primary element is workflow which influences monitoring of patients by nurses. General ward facilities typically monitor patients and check vitals every few hours with greater patient-to-nurse ratios, while acute care or post-operative wards have more frequent evaluations (Vincent et al., 2018). However, even in acute hospitals with rapid-response systems in place, the response protocol can be put off by deliberation or impact of workload and staffing (Chua et al., 2017).
Track and trigger charts within rapid-response systems often have algorithms to adhere meant to evaluate patients. However, nurses find it difficult to follow these due to heavy workloads and data not being updated on a timely basis by medical officers. An intervention employed by many nurses is to utilize a simplified early warning score system which takes into consideration potential factors that can impact patient deterioration. It allows for more leniency and familiarity of nurses with the patients presenting risks, thus increasing the potential for early identification (Wood et al., 2019). However, early warning score systems can be inconsistent, and inherently require developing unique variables based on each facility and its patient population. These can serve as a supplement to existing algorithmic systems and still encourage holistic assessment of patients for early recognition (Bedoya et al., 2019).
Symptoms of Clinical Deterioration and Pathophysiology
The first symptom of clinical deterioration for Mr. Clements is hypotension. The morning assessment showed a reading of 90/46 mmHG. Hypotension can be characterized by a low pulse, disorientation, and pale skin, all of which are indicative of insufficient blood flow seen in the patient (HealthDirect, 2018). Also, both aspirin and isosorbide mononitrate, given to Mr. Clements for reducing risk of hypertension and myocardial infraction, can potentially lower blood pressure below normal levels. While systolic pressure is lower than normal, the biggest drop is seen in the diastolic pressure of 46.
This has recently been termed as isolated diastolic hypotension, giving more attention to the diastolic measurement in blood pressure indicators where clinicians typically only view the systolic measurement (Guichard et al., 2011). In older adults, which fits Mr. Clements’ demographic, isolated diastolic hypotension can be an increased risk for new or onset heart failure. When veins and arterioles dilate, as a result of medication, heart disorders, or little blood volume, veins dilate and increase blood capacity and encounter less resistance; thus, resulting in less blood returning to the heart and dropping the diastolic pressure. Coronary arteries are fed in the diastolic phase; thus, with low diastolic pressure, the heart will lack necessary blood and oxygen, also known as ischemia, which weakens the heart over time (Sheriff et al., 2017).
A second identified symptoms is hypoxia, a condition where the body is deprived of oxygen at the tissue level. This is commonly measured by an indicator known as SpO2 or oxygen saturation in the hemoglobin of the blood that has been enriched in the lungs. Normal SpO2 levels vary between 95% and 100%, although some individuals with conditions such as chronic lung disease can have levels around 90% (Beasley et al., 2015). Once it drops lower, as it did for Mr. Clements, it is an indicator of critical SpO2 levels which is known as hypoxemia. Once the lack of oxygen is seen in the tissue, it becomes hypoxia. Symptoms of hypoxia include fatigue and dizziness, numbness of extremities, and eventually cyanosis. The more severe hypoxia can induce disorientation, hallucination, irregular heartbeat, and death as vital organs are starved with lack of oxygen. Systemic adaptions to hypoxia include increased ventilation, cardiac output, and blood vessel growth (Lee et al., 2020). Therefore, the hypotension described in the paragraph above is directly tied to hypoxia as blood vessel growth results in the drop of diastolic pressure, which, in turn, leads to poor oxygen delivery for vital organs. Mr. Clements started to demonstrate disorientation and cyanosis, with an irregularly low heartbeat and visible tachypnea.
Priority Problem
Based on the examined symptoms of patient deterioration and other data presented for Mr. Clements, the priority issue for this case is decreased cardiac output. It is a severe medical condition characterized by the heart not pumping enough blood to meet the needs and demands of the body. Patients with decreased cardiac output demonstrate a weak, irregular pulse, cold or pale skill, fatigue and disorientation, oliguria, hypotension, and tachypnea. A study by dos Santos et al. (2016) that in the immediate post-operative period after a coronary artery bypass, low cardiac output can be seen 75.9% of patients. Predictive risk factors include age >60, positive fluid balance, and post-operative arrhythmia.
It is a predictable, but nevertheless critical consequence after a serious heart surgery as myocardial performance declines while demand for cardiac output increases. With demand outweighing supply, with clinical manifestation of mismatched oxygen delivery and metabolic needs impacted by myocardial dysfunction and cardiovascular insufficiency – the body goes into shock. It is an issue that is multifactorial in etiology but can be caused by myocardial depression in the post-operative state, altered cardiac loading conditions, and inflammation affecting the hypermetabolic state (Epting et al., 2016). Decreased cardiac output is the priority issue in this case as it requires early identification and treatment, without which the shock may lead to heart failure and mortality.
Clinical Interventions
Desired nursing outcomes for this situation is to achieve adequate cardiac output which can be characterized by strong peripheral pulses with appropriate heart rate and a stable diastolic (as well systolic) blood pressure within the 90-120/60-80 mmHg parameters. Furthermore, hypoxia should be addressed by raising SpO2 levels preferably over 95% and ensuring the patient has warm skin indicative of proper circulation, and an appropriate level of consciousness and responsiveness.
The recommended nursing intervention for hypotension is to treat the patient with intravenous vasopressors and fluids. Generally, a mix of fluid solutions including saline and electrolytes can be helpful. IV fluids improve hydration which increases blood flow and improves hypotension symptoms. In some cases, ephedrine, an indirect alpha and beta-adrenergic agonist, is used, as well as aids with increasing heart rate and maintaining cardiac levels. Norepinephrine can be used as well to restore blood pressure to baseline levels and helps with treatment of shock (Lonjaret et al., 2014).
Since Mr. Clements is already receiving 2L/min of oxygen via nasal prongs, it is evident this is ineffective in maintaining appropriate SpO2 levels to prevent hypoxia. An appropriate intervention for hypoxia in patients with COPD demonstrating low SpO2 levels would be to shift the treatment algorithm for oxygen therapy. The Thoracic Society of Australia and New Zealand Clinical Practice Guidelines suggest using 2-4L/min via a 24% or 28% Venturi mask oxygen delivery. Nurses should titrate oxygen to achieve the SpO of 92%. It is possible to provide a bronchodilator which is meant to relax the lungs for breathing. If all these interventions fail, medical professionals should consider invasive ventilation alongside an ICU admission (Beasley, 2015).
Conclusion
Clinical deterioration is a serious issue for in-patient medical facilities, as early identification and interventions for patients can avoid preventable mortalities. Patients such as Mr. Clements who are at risk due to a variety of pre-existing health conditions in a postoperative state, should be monitored closely. This paper identified the importance and symptoms for the priority issue decreased cardiac output that is common in the postoperative period for cardiac surgeries, but can cause mortality for older individuals without early identification. Appropriate interventions for the issue were discussed and with prioritization of their implementation, it is possible to avoid clinical deterioration for Mr. Clements.
References
Australian Commission on Safety and Quality in Health Care. (2020). Recognising and responding to acute deterioration standard.Web.
Beasley, R., Chien, J., Douglas, J., Eastlake, L., Farah, C., King, G., Moore, R., & Pilcher, J. (2015). Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: ‘Swimming between the flags.’Respirology, 20(8), 1182–1191. Web.
These clinical guidelines provide a comprehensive outline regarding conditions such as hypoxia, COPD, and how to treat them. Offer critical information regarding SpO2 levels and how to manage them. Will be used to define symptoms and interventions for the patient.
Bedoya, A. D., Clement, M. E., Phelan, M., Steorts, R. C., O’Brien, C., & Goldstein, B. A. (2019). Minimal impact of implemented early warning score and best practice alert for patient deterioration.Critical Care Medicine, 47(1), 49–55. Web.
Offers an evidence-based approach to potential early identification of patient deterioration. Helpful among nurses to not overly on algorithms and machinery. Score system has to be unique to each facility based on population.
Chua, W. L., See, M. T. A., Legido-Quigley, H., Jones, D., Tee, A., & Liaw, S. Y. (2017). Factors influencing the activation of the rapid response system for clinically deteriorating patients by frontline ward clinicians: a systematic review.International Journal for Quality in Health Care, 29(8), 981–998. Web.
de Vries, E. N., Ramrattan, M. A., Smorenburg, S. M., Gouma, D. J., & Boermeester, M. A. (2008). The incidence and nature of in-hospital adverse events: a systematic review.Quality & Safety in Health Care, 17(3), 216–223. Web.
dos Santos, E. R., Lopes, C. T., Maria, V. L. R., & de Barros, A. L. B. L. (2016). Risk factors for decreased cardiac output after coronary artery bypass grafting: a prospective cohort study.European Journal of Cardiovascular Nursing, 16(4), 352–359. Web.
Describes risk factors and outcomes after coronary artery bypass for aging patients. Helpful in highlighting the critical nature of the issue. Source used to support the prioritization of the decreased cardiac output issue for the case study.
Epting, C.L., McBride, M. E., Wald, E. L., & Costello, J. M. (2016). Pathophysiology of post-operative low cardiac output syndrome. Current Vascular Pharmacology, 14, 14-23.
Highly detailed account of the pathophysiology for decreased cardiac output. Explains various causal factors which may influence the patient state. Emphasizes anatomical structures and their functions or failures for the condition.
Guichard, J. L., Desai, R. V., Ahmed, M. I., Mujib, M., Fonarow, G. C., Feller, M. A., Ekundayo, O. J., Bittner, V., Aban, I. B., White, M., Aronow, W. S., Love, T. E., Bakris, G. L., Zieman, S. J., & Ahmed, A. (2011). Isolated diastolic hypotension and incident heart failure in older adults.Hypertension, 58(5), 895–901. Web.
A well-known paper which first defined isolated diastolic hypotension in such detail. Provides epidemiology and some pathophysiology to this common occurrence. Relates IDH to viable risk factors and populations.
HealthDirect. (2018). Low blood pressure (hypotension). Web.
Lee, P., Chandel, N. S., & Simon, M. C. (2020). Cellular adaptation to hypoxia through hypoxia inducible factors and beyond.Nature Reviews Molecular Cell Biology, 21, 268-283. Web.
Discusses the biology and pathophysiology behind hypoxia. Explore influencing factors to the onset of hypoxia and common exemplification. Describes the mechanism of response to hypoxia viable to this paper.
Lonjaret, L., Lairez, O., Minville, V., & Geeraerts, T. (2014). Optimal perioperative management of arterial blood pressure.Integrated Blood Pressure Control, 7, 49–59. Web.
Massey, D., Chaboyer, W., & Anderson, V. (2016). What factors influence ward nurses’ recognition of and response to patient deterioration? An integrative review of the literature.Nursing Open, 4(1), 6–23. Web.
NHLBI. (n.d.). Cardiogenic shock. Web.
Sheriff, H. M., Tsimploulis, A., Valentova, M., Anker, M. S., Deedwania, P., Banach, M., Morgan, C. J., Blackman, M. R., Fonarow, G. C., White, M., Alagiakrishnan, K., Allman, R. M., Aronow, W. S., Anker, S. D., & Ahmed, A. (2017). Isolated diastolic hypertension and incident heart failure in community-dwelling older adults: Insights from the Cardiovascular Health Study.International Journal of Cardiology, 238, 140–143. Web.
Vahdatpour, C., Collins, D., & Goldberg, S. (2019). Cardiogenic shock.Journal of the American Heart Association, 8(8). Web.
A highly detailed and comprehensive description of cardiogenic shock. Explains the pathophysiological mechanisms of the condition. Outlines key symptoms and vital sign measurements indicative of cardiogenic shock.
Vincent, J. L., Einav, S., Pearse, R., Jaber, S., Kranke, P., Overdyk, F. J., Whitaker, D. K., Gordo, F., Dahan, A., & Hoeft, A. (2018). Improving detection of patient deterioration in the general hospital ward environment.European Journal of Anaesthesiology, 35(5), 325–333. Web.
Explores the challenges of patient deterioration detection in non-acute wards. Discusses the importance of identifying deterioration and its triggering of appropriate management. Develops options on improving patient monitoring.
Wood, C., Chaboyer, W., & Carr, P. (2019). How do nurses use early warning scoring systems to detect and act on patient deterioration to ensure patient safety? A scoping review.International Journal of Nursing Studies, 94, 166–178. Web.