Case Analysis: Medical Surgical Nursing

XAVIER UNIVERSITY – ATENEO DE CAGAYAN
COLLEGE OF NURSING
IN PARTIAL FULFILLMENT FOR THE REQUIREMENTS OF
NCM 112 – MEDICAL-SURGICAL NURSING
SUBMITTED BY:
MA. THERESE P. BALLARES
BSN 3 – NB
SUBMITTED TO:
MA. JESSECA P. MONSANTO, RN, MAN
CLINICAL INSTRUCTOR
AUGUST 30, 2020

CASE ANALYSIS GUIDE QUESTIONS
1. Identify and list Patient C's risk factors for developing atherosclerosis.
 Age (44 years old)

 Family history of early CHD among the men & type 2 Diabetes among the
women
 Frequent alcohol intake
 High cholesterol level (hyperlipidemia)
 No regular exercise program
 Overweight
 Smoking occasionally
 Stress (work)
2. Define the etiology, pathology, clinical manifestations, and therapeutic

treatment of carcinogenic shock. What clinical clues in this case suggest cardiogenic
shock?
 ETIOLOGY
 Acute anterior and inferior Myocardial infarction
 Anxiety
 Damage to your heart’s right ventricle
 Decreased level of consciousness
 Drug overdoses or poisoning with substances that can affect your heart's
pumping ability
 Femoral arteries – faint in lower extremities below the groin
 Hypoxia
 Inflammation of the heart muscle (myocarditis)
 Infection of the heart valves (endocarditis)
 Jugular vein distention to angle of jaw while supine
 Lack of oxygen to your heart
 Moist rales, and rhonchi scattered through both lung fields
 Normal sinus rhythm with frequent PVCs
 Overweight
 Pale, dusky skin, gray, diaphoretic, dyspneic Hispanic man
 Respiratory rate – 24bpm (tachypnea)
 Shortness of breath
 Weakened heart from any cause
 PATHOLOGY
Cardiogenic shock is characterized by systolic and diastolic dysfunction

which leads to hypo-perfusion of the end-organs. The disruption of blood flow
in an epicardial coronary artery causes the vessel to lose the ability to shorten
and conduct contractile function in the myocardial zone supplied. If there is
ischemic damage to a large region of myocardium, the role of the LV pump
becomes impaired and systemic hypotension occurs.
Patients that experience an acute MI cardiogenic shock typically display

progressive myocardial necrosis with extension of the infarct. In the vicious
cycle that leads to cardiogenic shock and potentially death, reduced coronary
perfusion pressure and cardiac production as well as increased demand for
myocardial oxygen play a part.
Patients with cardiogenic shock also suffer from multi-vessel coronary

artery disease with insufficient reserve of coronary blood flow. Myocardial
diastolic function is also compromised as ischemia reduces myocardial
compliance and impairs filling, raising the LV filling pressure and contributing to
pulmonary edema and hypoxemia.
 CLINICAL MANIFESTATIONS
 Cold hands or feet
 Loss of consciousness
 Low blood pressure (hypotension)
 Pale skin
 Rapid breathing
 Severe shortness of breath
 Sudden, rapid heartbeat (tachycardia)
 Sweating
 Urinating less than normal or not at all
 Weak pulse
 Because cardiogenic shock typically happens in people who have a serious

heart attack, knowing the signs and symptoms of a heart attack is crucial. These
include:
 Pressure, fullness or a squeezing pain in the center of your chest that lasts
for more than a few minutes
 Pain extending to your shoulder, one or both arms, back, or even to your
teeth and jaw
 Increasing episodes of chest pain
 Shortness of breath
 Sweating
 Lightheadedness or sudden dizziness
 Nausea and vomiting
 THERAPEUTIC TREATMENT
Cardiogenic shock is life-threatening and requires immediate diagnosis

and identification of the cause and medical attention for emergencies.
Treatments include medications, cardiac operations and medical devices to
help or restore the body’s blood supply and avoid damage to the organ.
Because cardiogenic shock is a severe medical condition that affects

multiple organs of the body, a team of medical professionals typically provide
treatment. Some medical devices can be used for stabilizing or helping you
temporarily before a permanent device can be inserted or a heart transplant
can be carried out.
For people who experience serious organ damage and may not survive
after cardiogenic shock, palliative care or hospice care may help them with less
symptoms to have a better quality of life.
 CLINICAL CLUES
 Atrial and ventricular rate (114 bpm)
 Chest discomfort unrelated to exertion
 Collapsed at the airport prior to departing on a business trip
 ECG shows sinus tachycardia with frequent PVCs
 Going hypotensive (98/62 mmHg)
 Pale general appearance
 Rapid Breathing (24 bpm)
 Shortness of Breath
 ST segment elevation & depression noted
 Tachycardia
3. Explain the rationale for the use of dobutamine, dopamine, and norepinephrine
to support blood pressure in the management of shock.
DRUGS RATIONALE
Dobutamine - It is a (sympathomimetic agent) beta 1-receptor agonist, has

some beta 2-receptor and minimal alpha-receptor activity
- It induces significant positive inotropic effects, with mild
chronotropic effects; also induces mild peripheral vasodilation
(decrease in afterload)
- To improve myocardial contractility; it also decrease left
ventricular end-diastolic pressure and raises blood pressure by
increasing cardiac output
Dopamine - To cause a vasodilation of renal, mesenteric, and coronary
beds
- To increase myocardial activity, and supports the blood
pressure;
- With its dosage at 5mg/kg/minute, beta 1-adrenergic effects
induce an increase in cardiac contractility and heart rate
Norepinephrine - A potent alpha-adrenergic agonist with only minor beta 1-

adrenergic agonist effects
- It can increase patient’s blood pressure successfully if he
remains hypotensive following dopamine
4. What nursing outcomes would be desirable for Patient C?
 Absence of respiratory dysfunction

 Absence or early detection of complications
 Achievement of activity level sufficient for basic self-care
 Chest pain absent/controlled
 Disease process, treatment plan, and prognosis understood
 Express feelings and exhibit adequate coping mechanisms
 Maintain adequate cardiac output and hemodynamic stability
 Maintain adequate ventilation
 Maintenance or attainment of adequate tissue perfusion
 Plan in place to meet needs after discharge
 Prevent/detect and assist in treatment of life-threatening dysrhythmias or
complications
 Prevention of myocardial damage
 Promote cardiac health, self-care
 Reduce myocardial workload
 Reduced anxiety
 Relief of pain or ischemic signs and symptoms
5. What interventions are needed to accomplish these outcomes?
 Administer oxygen along with medication therapy to assist with relief of

symptoms
 Check skin temperature and peripheral pulses frequently to monitor tissue
perfusion
 Encourage bed rest with the backrest elevated to help decrease chest
discomfort and dyspnea
 Encourage changing of positions frequently to help keep fluid from pooling
in the bases of the lungs
 Encourage the client to avoid smoking, and stop alcohol intake
 Instruct client to strictly adhere to his diet such to eat food less saturated fat
and cholesterol
 Provide information in an honest and supportive manner
 Monitor the patient closely for changes in cardiac rate and rhythm, heart
sounds, blood pressure, chest pain, respiratory status, urinary output,
changes in skin color, and laboratory values
6. What interventions would be appropriate if Patient C continues to state that he

wishes to leave the hospital?
 Encourage client to take regular physical activity

 Have client demonstrate understanding of health teachings
 Have client demonstrate knowledge on the importance of the adherence to
diet and lifestyle changes and/or restriction
 Inform client to have a follow-up check-up
 Encourage the client to avoid smoking
 Encourage diminished alcohol intake to within recommended safe limits and
avoid binge drinking
 Teach the patient to call 911 for any chest pain that is not relieved by rest
and/or nitroglycerin.
 Instruct the patient not to ignore the pain or wait to call for assistance.
References
Anderson, J. L., & Morrow, D. A. (2017). Acute myocardial infarction. New England
Journal of Medicine, 376(21), 2053-2064.
Atherosclerosis. (n.d.). Retrieved August 29, 2020, from

https://www.nhlbi.nih.gov/health-topics/atherosclerosis?fbclid=IwAR3sA1r462HViT-
4DPhFxAi-_pdSbaEboGljiDCj0Ctq8chVbadeM4FTeZY
Cardiogenic Shock (2017). Retrieved from https://www.mayoclinic.org/diseases-

conditions/cardiogenic-shock/symptoms-causes/syc-20366739
Cardiogenic Shock (2016). Retrieved from https://www.nhlbi.nih.gov/health-

topics/cardiogenic-
shock#:~:text=Cardiogenic%20shock%20can%20be%20caused,no%20longer%20p
umps%20blood%20effectively.
Cardiogenic Shock: Diseases and Disorders. (n.d.). Retrieved August 29, 2020, from
https://nursing.unboundmedicine.com/nursingcentral/view/Diseases-and-
Disorders/73546/all/Cardiogenic_Shock?fbclid=IwAR2SYKbjUDUwVY3Zn0NNm2CP
O4c2LHZCJ9BLIZq9E8zcf-hgQ0fO3dclcg4
Diet Change to Reduce Residual Risk After Myocardial Infarction (2016). Retrieved
from https://www.acc.org/education-and-meetings/patient-case-quizzes/diet-change-
to-reduce-residual-risk-after-myocardial-infarction
McGraw, S. J. (2007). Medical-surgical nursing (910441228 716623013 A. Moshier
& 910441229 716623013 T. M. Kear, Eds.). Philadelphia: Lippincott Williams
& Wilkins.
Musher, D. M., Abers, M. S., & Corrales-Medina, V. F. (2019). Acute infection and
myocardial infarction. New England Journal of Medicine, 380(2), 171-176.
Secondary prevention for patients following a myocardial infarction: summary of NICE

guidance (2007). Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1994451/#:~:text=Eat%20a%20Medit
erranean%E2%80%90style%20diet,of%20oily%20fish%20per%20week.
Van Diepen, S., Katz, J. N., Albert, N. M., Henry, T. D., Jacobs, A. K., Kapur, N. K., ...
& Thiele, H. (2017). Contemporary management of cardiogenic shock: a scientific
statement from the American Heart Association. Circulation, 136(16), e232-e268.

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XAVIER UNIVERSITY – ATENEO DE CAGAYAN

IN PARTIAL FULFILLMENT FOR THE REQUIREMENTS OF

NCM 112 – MEDICAL-SURGICAL NURSING

MA. THERESE P. BALLARES

MA. JESSECA P. MONSANTO, RN, MAN

AUGUST 30, 2020

 Age (44 years old)

2. Define the etiology, pathology, clinical manifestations, and therapeutic

Cardiogenic shock is characterized by systolic and diastolic dysfunction

Patients that experience an acute MI cardiogenic shock typically display

Patients with cardiogenic shock also suffer from multi-vessel coronary

 Because cardiogenic shock typically happens in people who have a serious

Cardiogenic shock is life-threatening and requires immediate diagnosis

Because cardiogenic shock is a severe medical condition that affects

Dobutamine - It is a (sympathomimetic agent) beta 1-receptor agonist, has

Norepinephrine - A potent alpha-adrenergic agonist with only minor beta 1-

4. What nursing outcomes would be desirable for Patient C?

 Absence of respiratory dysfunction

 Administer oxygen along with medication therapy to assist with relief of

6. What interventions would be appropriate if Patient C continues to state that he

 Encourage client to take regular physical activity

Atherosclerosis. (n.d.). Retrieved August 29, 2020, from

Cardiogenic Shock (2017). Retrieved from https://www.mayoclinic.org/diseases-

Cardiogenic Shock (2016). Retrieved from https://www.nhlbi.nih.gov/health-

Secondary prevention for patients following a myocardial infarction: summary of NICE

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