Nursing Care Plan for Cardiogenic Shock

Posted on by Soumya Ranjan Parida
Nursing Care Plan for Cardiogenic Shock: Comprehensive Guide

Nursing Care Plan for Cardiogenic Shock

A Comprehensive Guide for Nursing Students

Introduction

Cardiogenic shock represents a life-threatening emergency characterized by severe impairment of cardiac function, resulting in inadequate tissue perfusion. As one of the most critical conditions that nurses encounter in acute care settings, understanding how to manage cardiogenic shock is essential for delivering high-quality patient care and improving survival outcomes.

This comprehensive guide provides nursing students with essential knowledge and 15 detailed nursing care plans for managing patients with cardiogenic shock. Using the osmosis approach of breaking down complex concepts into understandable components, this resource aims to enhance clinical reasoning and decision-making skills in critical care scenarios.

Table of Contents

  1. Definition and Overview
  2. Pathophysiology
  3. Etiology and Precipitating Factors
  4. Clinical Manifestations
  5. Diagnostic Assessment
  6. Nursing Care Plans
    1. Decreased Cardiac Output
    2. Ineffective Tissue Perfusion
    3. Impaired Gas Exchange
    4. Acute Pain
    5. Risk for Decreased Cardiac Tissue Perfusion
    6. Anxiety
    7. Deficient Knowledge
    8. Risk for Electrolyte Imbalance
    9. Activity Intolerance
    10. Excess Fluid Volume
    11. Altered Nutrition: Less than Body Requirements
    12. Risk for Infection
    13. Impaired Skin Integrity
    14. Disturbed Sleep Pattern
    15. Compromised Family Coping
  7. Pharmacological Management
  8. Mechanical Support Therapies
  9. Prevention and Risk Reduction
  10. Conclusion

Definition and Overview

Cardiogenic shock is a condition of inadequate tissue perfusion resulting from cardiac pump failure. It occurs when the heart is unable to generate sufficient cardiac output to meet the metabolic demands of the body, despite adequate intravascular volume.

Key Features of Cardiogenic Shock:

  • Systolic blood pressure < 90 mmHg for at least 30 minutes
  • Reduced cardiac index (< 2.2 L/min/m²)
  • Elevated pulmonary capillary wedge pressure (> 15 mmHg)
  • Signs of end-organ hypoperfusion (altered mental status, cold extremities, oliguria, elevated lactate)

Cardiogenic shock is associated with high mortality rates ranging from 40-80%, emphasizing the critical importance of early recognition and aggressive management by the healthcare team. The primary goal of nursing care is to improve cardiac function, maintain adequate tissue perfusion, prevent complications, and provide emotional support to patients and their families.

Pathophysiology

Understanding the pathophysiology of cardiogenic shock is crucial for implementing effective nursing interventions. The cycle begins with an initiating event and can rapidly progress to a fatal outcome if not properly managed.

The Cycle of Cardiogenic Shock:

Stage Pathophysiological Changes Clinical Implications
Initial Cardiac Insult Myocardial damage (often MI), leading to decreased contractility Reduced stroke volume and cardiac output
Compensatory Response Sympathetic activation, increased heart rate, vasoconstriction Increased myocardial oxygen demand, potentially worsening ischemia
Progression Decreased coronary perfusion, worsening cardiac function Progressive hypoxia and acidosis, further depressing myocardial function
Systemic Effects Systemic inflammatory response, microvascular dysfunction Multi-organ dysfunction syndrome (MODS)

The Vicious Cycle:

Cardiogenic shock initiates a downward spiral where:

  1. ↓ Cardiac output → ↓ Blood pressure → ↓ Coronary perfusion
  2. ↓ Coronary perfusion → ↑ Myocardial ischemia → ↓ Contractility
  3. ↓ Contractility → ↓ Cardiac output (cycle continues)

Nursing Insight:

The nurse’s understanding of this pathophysiological cycle is essential for recognizing the need for interventions aimed at breaking this cycle through improving cardiac function, reducing afterload, and ensuring adequate coronary perfusion.

Etiology and Precipitating Factors

Cardiogenic shock can result from various cardiac conditions that impair the heart’s ability to pump effectively. Identifying the underlying cause is crucial for appropriate management.

Primary Causes

  • Acute myocardial infarction (most common cause, 75-80% of cases)
  • End-stage cardiomyopathy (dilated, hypertrophic, restrictive)
  • Myocarditis
  • Advanced valvular heart disease
  • Cardiac tamponade
  • Ventricular septal rupture
  • Papillary muscle rupture with severe mitral regurgitation

Contributing Factors

  • Medication non-adherence in heart failure patients
  • Arrhythmias (especially ventricular tachycardia, atrial fibrillation)
  • Severe hypertensive crisis
  • Pulmonary embolism
  • Sepsis (septic shock can lead to cardiogenic component)
  • Drug toxicity (beta-blockers, calcium channel blockers)
  • Electrolyte disturbances

Distribution of Causes in Cardiogenic Shock:

  • Acute Myocardial Infarction: 75-80%
    • Left ventricular failure: 78.5%
    • Ventricular septal rupture: 3.9%
    • Papillary muscle rupture: 6.9%
    • Right ventricular failure: 2.8%
  • Non-MI Causes: 20-25%

Important Clinical Consideration:

Cardiogenic shock typically develops when 40% or more of the left ventricular myocardium is damaged. Early identification of the specific cause is essential for targeted therapy and improved outcomes.

Clinical Manifestations

The clinical presentation of cardiogenic shock reflects both the hemodynamic compromise and the body’s compensatory mechanisms. Nurses must be vigilant in recognizing these signs, which can be organized by body system.

System Clinical Manifestations Nursing Assessment Focus
Cardiovascular
  • Hypotension (SBP <90 mmHg)
  • Tachycardia
  • Weak, thready pulse
  • Distant heart sounds
  • S3, S4 gallops
  • Murmurs (if valve dysfunction)
  • JVD (jugular venous distention)
  • Narrow pulse pressure
  • Continuous hemodynamic monitoring
  • Trend in vital signs
  • Heart sounds and rhythm
  • Perfusion indices
Respiratory
  • Tachypnea
  • Dyspnea
  • Crackles/rales
  • Pulmonary edema
  • Pink, frothy sputum
  • Decreased oxygen saturation
  • Respiratory rate and effort
  • Breath sounds
  • Sputum characteristics
  • ABG values
  • Oxygen requirements
Neurological
  • Altered mental status
  • Confusion
  • Restlessness
  • Agitation
  • Lethargy progressing to coma
  • Level of consciousness
  • GCS score
  • Pupillary responses
  • Orientation
Renal
  • Oliguria (<30 ml/hr)
  • Anuria
  • Electrolyte imbalances
  • Elevated BUN and creatinine
  • Urine output
  • Fluid balance
  • Renal function tests
  • Electrolyte levels
Integumentary
  • Cool, clammy skin
  • Pallor
  • Cyanosis (peripheral, central)
  • Delayed capillary refill (>3 seconds)
  • Mottling
  • Skin temperature and color
  • Capillary refill
  • Peripheral pulses
  • Signs of tissue hypoxia
Gastrointestinal
  • Decreased appetite
  • Nausea/vomiting
  • Abdominal pain
  • Elevated liver enzymes
  • Hepatomegaly
  • Abdominal assessment
  • Bowel sounds
  • GI function
  • Nutritional status

Clinical Pearls:

The classic presentation of “cold and clammy” extremities differentiates cardiogenic shock from septic shock, which often presents with warm, flushed skin. However, mixed shock states can occur, complicating the clinical picture.

Diagnostic Assessment

Diagnostic evaluation of cardiogenic shock involves a comprehensive approach to confirm the diagnosis, identify the underlying cause, assess severity, and guide management decisions.

Laboratory Studies

Test Expected Findings Nursing Implications
Cardiac Biomarkers Elevated troponin I, troponin T, CK-MB Indicates myocardial injury; serial monitoring needed to track progression
BNP/NT-proBNP Elevated levels Confirms heart failure component; useful for monitoring treatment response
Arterial Blood Gases Metabolic acidosis, respiratory alkalosis, hypoxemia Assess tissue oxygenation and acid-base status; guide ventilatory support
Lactate Elevated (>2 mmol/L) Indicates tissue hypoperfusion; serves as prognostic marker
Complete Blood Count Variable; anemia may be present Assess for contributing factors; monitor for bleeding if on anticoagulants
Basic Metabolic Panel Electrolyte imbalances, elevated BUN/creatinine Monitor renal function and electrolyte status; adjust medication dosing
Liver Function Tests Elevated transaminases, bilirubin Assess for hepatic congestion and hypoperfusion; adjust medication dosing
Coagulation Profile Prolonged PT/INR, PTT Assess for coagulopathy; guide anticoagulation therapy

Diagnostic Imaging & Procedures

Study Purpose Findings in Cardiogenic Shock
12-Lead ECG Detect myocardial ischemia/infarction, arrhythmias ST elevation/depression, Q waves, arrhythmias, conduction abnormalities
Chest X-ray Assess cardiac size, pulmonary congestion Cardiomegaly, pulmonary edema, pleural effusion, vascular congestion
Echocardiography Evaluate cardiac structure and function Reduced EF, wall motion abnormalities, valvular dysfunction, mechanical complications
Cardiac Catheterization Assess coronary anatomy, hemodynamics Coronary occlusions, LVEDP >18 mmHg, cardiac index <2.2 L/min/m²
Pulmonary Artery Catheter Direct hemodynamic monitoring Elevated PCWP >15 mmHg, reduced cardiac output, elevated SVR
CT Angiography Rule out pulmonary embolism, aortic dissection Filling defects (PE), dissection flap (aortic dissection)

Hemodynamic Parameters in Cardiogenic Shock:

  • Cardiac Index: <2.2 L/min/m²
  • Pulmonary Capillary Wedge Pressure: >15 mmHg
  • Systemic Vascular Resistance: >1500 dyn·s/cm⁵
  • Mixed Venous Oxygen Saturation: <60%
  • Stroke Volume Index: <30 ml/beat/m²

Nursing Consideration:

The nurse plays a critical role in coordinating diagnostic testing, ensuring timely collection of specimens, preparing patients for procedures, and monitoring for complications during and after invasive diagnostics.

Nursing Care Plans for Cardiogenic Shock

The following 15 nursing care plans address the holistic needs of patients experiencing cardiogenic shock. Each care plan follows the nursing process framework and includes NANDA diagnoses, nursing interventions, rationales, and expected outcomes.

1. Decreased Cardiac Output

Priority Hemodynamic Vital

NANDA Definition: Inadequate blood pumped by the heart to meet the metabolic demands of the body.

Related Factors:

  • Myocardial infarction/ischemia
  • Alterations in contractility
  • Alterations in preload/afterload
  • Mechanical complications (valvular dysfunction, rupture)
  • Dysrhythmias

Defining Characteristics:

  • Hypotension (SBP <90 mmHg)
  • Tachycardia
  • Decreased peripheral pulses
  • Cool, clammy skin
  • Decreased urine output (<30 ml/hr)
  • Altered mental status
  • S3, S4 heart sounds
  • Pulmonary congestion
  • Decreased cardiac index (<2.2 L/min/m²)

Expected Outcomes:

  • Patient will maintain adequate cardiac output as evidenced by:
    • SBP >90 mmHg
    • Heart rate 60-100 bpm
    • Urine output >30 ml/hour
    • Warm extremities with capillary refill <3 seconds
    • Improved mental status
    • Cardiac index >2.2 L/min/m²
    • Mixed venous oxygen saturation >65%
Nursing Interventions Rationale
1. Monitor and document vital signs, hemodynamic parameters, and clinical status at least hourly or more frequently as indicated:
  • Blood pressure, heart rate, respiratory rate
  • Cardiac output/index
  • Pulmonary artery pressures
  • PCWP, CVP
  • SVR, PVR
  • SvO₂/ScvO₂
 Provides data about cardiovascular status and effectiveness of interventions. Trending parameters helps detect early deterioration and guides titration of therapies.
2. Administer inotropic agents and vasopressors as prescribed:
  • Dobutamine: Starting at 2-5 mcg/kg/min, titrate up to 20 mcg/kg/min
  • Norepinephrine: 0.01-3 mcg/kg/min
  • Dopamine: 5-15 mcg/kg/min
  • Epinephrine: 0.01-0.5 mcg/kg/min
 Inotropes increase myocardial contractility and cardiac output. Vasopressors maintain coronary perfusion pressure and systemic circulation. Different agents affect alpha and beta receptors differently, requiring careful selection based on patient needs.
3. Administer vasodilators cautiously as prescribed (nitroglycerin, nitroprusside) when blood pressure allows. Reduces afterload and preload, decreasing myocardial workload and oxygen consumption. Must be used cautiously to avoid hypotension, which could worsen coronary perfusion.
4. Position patient in semi-Fowler’s position (30°) unless contraindicated. Reduces venous return (preload) and myocardial oxygen demand while optimizing ventilation and reducing pulmonary congestion.
5. Monitor fluid status carefully; administer fluids judiciously based on hemodynamic parameters. Patients with cardiogenic shock may have mixed volume status. Some require volume for optimal preload while others develop pulmonary edema with excessive fluids.
6. Minimize oxygen demand:
  • Maintain normothermia
  • Provide adequate pain management
  • Facilitate rest periods
  • Cluster nursing activities
 Reduces myocardial oxygen consumption and prevents further cardiac compromise. Pain, fever, and activity increase metabolic demands and oxygen requirements.
7. Collaborate with the healthcare team regarding the need for mechanical circulatory support:
  • Intra-aortic balloon pump (IABP)
  • Extracorporeal membrane oxygenation (ECMO)
  • Ventricular assist devices (VAD)
 Mechanical circulatory support devices can temporarily maintain circulation and perfusion while allowing the heart to recover or serving as a bridge to definitive therapy.
8. Continuously monitor cardiac rhythm and treat arrhythmias promptly. Arrhythmias can further compromise cardiac output. Prompt recognition and treatment prevent further deterioration.

Evaluation:

  • Assess hemodynamic parameters every 1-2 hours and with any change in condition
  • Compare current status with expected outcomes
  • Modify care plan based on response to interventions
  • Document improvements or deterioration in cardiac function

2. Ineffective Tissue Perfusion

Priority Circulatory Vital

NANDA Definition: Decrease in oxygen resulting in the failure to nourish tissues at the capillary level.

Related Factors:

  • Decreased cardiac output
  • Hypovolemia
  • Interruption of blood flow
  • Vasoconstriction
  • Microcirculatory dysfunction

Defining Characteristics:

  • Altered mental status
  • Decreased peripheral pulses
  • Cool extremities
  • Pallor or cyanosis
  • Delayed capillary refill (>3 seconds)
  • Decreased urine output
  • Elevated serum lactate
  • Metabolic acidosis
  • Altered organ function

Expected Outcomes:

  • Patient will demonstrate improved tissue perfusion as evidenced by:
    • Alert and oriented mental status
    • Palpable peripheral pulses
    • Warm extremities
    • Capillary refill <3 seconds
    • Urine output >30 ml/hour
    • Decreasing serum lactate levels
    • Improved acid-base balance
Nursing Interventions Rationale
1. Assess and document peripheral perfusion hourly:
  • Skin temperature, color
  • Capillary refill
  • Peripheral pulses
  • Neurological status
 Provides information about tissue perfusion at the peripheral level and helps evaluate the effectiveness of interventions.
2. Monitor urine output hourly (maintain >0.5 ml/kg/hr). Urine output is a sensitive indicator of renal perfusion and overall tissue perfusion status.
3. Monitor laboratory values reflecting tissue perfusion:
  • Serum lactate (goal: <2 mmol/L)
  • Arterial blood gases
  • Base deficit
  • Mixed venous oxygen saturation (SvO₂ >65%)
 These markers provide objective data about tissue oxygenation and cellular metabolism. Elevated lactate and base deficit indicate anaerobic metabolism due to inadequate tissue perfusion.
4. Administer prescribed vasoactive medications to optimize perfusion pressure:
  • Titrate to maintain MAP >65 mmHg
  • Balance adequate perfusion pressure with minimizing afterload
 Maintaining adequate mean arterial pressure ensures perfusion to vital organs. However, excessive vasoconstriction can increase cardiac workload and further compromise tissue perfusion.
5. Administer supplemental oxygen to maintain SpO₂ >94%. Maximizes oxygen delivery to tissues by ensuring adequate arterial oxygen content.
6. Monitor for signs of developing multiple organ dysfunction:
  • Increasing BUN/creatinine (renal)
  • Elevated liver enzymes (hepatic)
  • Worsening oxygenation (pulmonary)
  • Altered mental status (neurological)
  • Thrombocytopenia, coagulopathy (hematological)
 Persistent tissue hypoperfusion leads to progressive organ dysfunction. Early recognition allows for prompt intervention.
7. Reposition patient at least every 2 hours, with special attention to pressure points. Prevents pressure injuries in tissue with already compromised perfusion.
8. Ensure proper positioning of extremities to optimize circulation (avoid knee gatch, tight clothing, crossing legs). Prevents further compromise to peripheral circulation and reduces risk of thrombosis.

Evaluation:

  • Assess peripheral perfusion with vital signs
  • Monitor trends in lactate levels and other markers of tissue perfusion
  • Evaluate urine output hourly
  • Assess for improvement in organ function

3. Impaired Gas Exchange

Priority Respiratory Vital

NANDA Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

Related Factors:

  • Pulmonary edema
  • Ventilation-perfusion mismatch
  • Alveolar-capillary membrane changes
  • Increased left atrial pressure
  • Respiratory muscle fatigue

Defining Characteristics:

  • Dyspnea
  • Tachypnea
  • Abnormal arterial blood gases (↓PaO₂, ↑PaCO₂)
  • Hypoxemia
  • Decreased oxygen saturation (<90%)
  • Use of accessory muscles
  • Crackles, rales
  • Pink, frothy sputum
  • Restlessness, confusion
  • Cyanosis

Expected Outcomes:

  • Patient will demonstrate improved gas exchange as evidenced by:
    • Respiratory rate 12-20 breaths/min
    • SpO₂ >94% on prescribed oxygen therapy
    • PaO₂ >80 mmHg
    • Normal pH and PaCO₂
    • Clear lung sounds
    • Reduced work of breathing
    • Improved mental status
Nursing Interventions Rationale
1. Assess and document respiratory status every 1-2 hours:
  • Respiratory rate, pattern, depth
  • Work of breathing
  • Breath sounds
  • SpO₂ and oxygen requirements
 Provides baseline for comparison and allows early detection of respiratory compromise. Changes in respiratory status often precede other signs of deterioration.
2. Administer supplemental oxygen as prescribed to maintain SpO₂ >94% or as ordered:
  • Titrate FiO₂ based on SpO₂ and ABG results
  • Use appropriate oxygen delivery device based on needs
 Supplemental oxygen increases arterial oxygen content and improves tissue oxygenation. The appropriate oxygen delivery device depends on the severity of hypoxemia and patient tolerance.
3. Position patient to optimize ventilation (30-45° semi-Fowler’s position unless contraindicated). Elevating the head of bed reduces work of breathing, improves lung expansion, and decreases pulmonary congestion by reducing venous return.
4. Monitor and interpret arterial blood gas results; report significant changes. ABGs provide the most accurate assessment of oxygenation, ventilation, and acid-base status.
5. Collaborate with respiratory therapy for:
  • Non-invasive positive pressure ventilation (CPAP/BiPAP) as indicated
  • Preparation for endotracheal intubation if respiratory failure develops
 Non-invasive ventilation can improve oxygenation and reduce work of breathing in cardiogenic pulmonary edema. Intubation may be necessary for severe respiratory failure.
6. Administer prescribed medications:
  • Diuretics (e.g., furosemide)
  • Morphine sulfate (if ordered, with caution)
  • Inotropes to improve cardiac output
 Diuretics reduce pulmonary congestion. Morphine may reduce preload and anxiety but should be used cautiously due to potential respiratory depression. Improving cardiac output reduces pulmonary congestion.
7. Assess for and promptly report signs of respiratory failure:
  • Increasing respiratory distress
  • Declining SpO₂ despite increasing O₂
  • Rising PaCO₂
  • Altered mental status
  • Inability to protect airway
 Early recognition of respiratory failure allows for timely intervention, including potential intubation and mechanical ventilation before cardiopulmonary arrest occurs.
8. Encourage deep breathing exercises if patient is alert and able. Deep breathing improves alveolar ventilation, promotes clearance of secretions, and prevents atelectasis.

Evaluation:

  • Monitor respiratory status, including oxygen saturation and work of breathing
  • Assess response to oxygen therapy and other interventions
  • Review ABG results to evaluate trends in oxygenation and acid-base status
  • Document changes in lung sounds and respiratory pattern
  • Modify interventions based on patient response

4. Acute Pain

Comfort Symptom Management

NANDA Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end.

Related Factors:

  • Myocardial ischemia
  • Tissue hypoxia
  • Angina
  • Inflammatory processes
  • Invasive procedures and monitoring devices
  • Prolonged immobility

Defining Characteristics:

  • Self-report of pain intensity and quality
  • Chest discomfort or pain (may be crushing, squeezing, pressure-like)
  • Pain that may radiate to jaw, neck, back, or arms
  • Guarding behavior
  • Facial expressions of pain
  • Diaphoresis
  • Increased heart rate and blood pressure
  • Restlessness
  • Nausea

Expected Outcomes:

  • Patient will report reduced pain as evidenced by:
    • Verbalization of pain relief
    • Pain score decreased to 3/10 or less or patient’s acceptable level
    • Relaxed facial expression and body posture
    • Ability to rest comfortably
    • Stable vital signs
Nursing Interventions Rationale
1. Assess pain comprehensively using an appropriate scale:
  • Location, quality, intensity (0-10), duration
  • Aggravating and relieving factors
  • Associated symptoms
  • For non-verbal patients, use behavioral pain scales
 Thorough pain assessment provides baseline data, guides treatment selection, and helps differentiate cardiac from non-cardiac pain. Regular reassessment evaluates effectiveness of interventions.
2. For suspected cardiac chest pain:
  • Administer prescribed nitroglycerin (if SBP >90 mmHg)
  • Provide supplemental oxygen if hypoxemic
  • Obtain 12-lead ECG
  • Notify physician/provider immediately
 Chest pain in cardiogenic shock may indicate ongoing ischemia requiring urgent intervention. Nitroglycerin dilates coronary arteries, improving myocardial perfusion. ECG helps identify ischemia/infarction requiring specific treatments.
3. Administer prescribed analgesics carefully:
  • Morphine sulfate (low dose, with caution)
  • Monitor respiratory status closely after administration
  • Have naloxone readily available
 Morphine reduces pain, anxiety, and preload but should be used cautiously due to potential hypotension and respiratory depression. Careful monitoring prevents adverse effects. Naloxone reverses opioid effects if needed.
4. Implement non-pharmacological pain management strategies:
  • Position of comfort (semi-Fowler’s typically)
  • Relaxation techniques (guided breathing)
  • Minimize environmental stressors (noise, lighting)
  • Provide calm reassurance
 Non-pharmacological methods can complement medication therapy, reduce anxiety, and provide psychological support without cardiovascular side effects. Anxiety reduction may decrease sympathetic stimulation that worsens myocardial oxygen demand.
5. Monitor vital signs before and after analgesic administration. Analgesics may affect hemodynamic parameters. Pain itself can increase myocardial oxygen demand through sympathetic stimulation, while pain relief may improve hemodynamics.
6. Assess for improvement or worsening of pain; document effectiveness of interventions. Persistent or worsening pain may indicate ongoing ischemia requiring additional interventions. Documentation provides evidence of response to treatment.
7. Minimize painful procedures when possible; consider clustering care activities to provide rest periods. Reduces pain triggers and provides periods of uninterrupted rest, reducing physiological stress and myocardial oxygen demand.
8. For pain related to invasive devices:
  • Secure lines properly to prevent traction
  • Provide site care according to protocol
  • Reposition as needed and allowed
 Proper care of invasive monitoring devices and lines reduces discomfort while maintaining their function. Repositioning prevents pressure injuries and musculoskeletal pain.

Evaluation:

  • Reassess pain using same scale after interventions
  • Monitor for complications of pain management (respiratory depression, hypotension)
  • Document pain characteristics, interventions, and responses
  • Modify pain management plan based on effectiveness

5. Risk for Decreased Cardiac Tissue Perfusion

Risk Hemodynamic Vital

NANDA Definition: Vulnerable to a decrease in cardiac (coronary) circulation, which may compromise health.

Risk Factors:

  • Hypotension
  • Hypovolemia
  • Coronary artery disease
  • Coronary artery spasm
  • Aortic dissection
  • Cardiac tamponade
  • Hypertrophic cardiomyopathy
  • Increased left ventricular end-diastolic pressure
  • Dysrhythmias

Expected Outcomes:

  • Patient will maintain adequate coronary perfusion as evidenced by:
    • Absence of chest pain
    • No new ECG changes indicating ischemia
    • Stable or improving cardiac biomarkers
    • Adequate coronary perfusion pressure (diastolic BP minus PCWP >30 mmHg)
    • Stable hemodynamic parameters
Nursing Interventions Rationale
1. Monitor and maintain adequate coronary perfusion pressure (CPP):
  • Calculate CPP (diastolic BP – PCWP)
  • Target CPP >30 mmHg
  • Titrate vasopressors to maintain diastolic BP >60 mmHg
 Coronary perfusion occurs primarily during diastole. Adequate diastolic pressure is crucial for myocardial blood flow, especially in compromised coronary circulation. Low CPP exacerbates myocardial ischemia.
2. Monitor for signs of myocardial ischemia:
  • Chest pain/discomfort
  • ECG changes (ST elevation/depression, T-wave changes)
  • New arrhythmias
  • Hemodynamic deterioration
 Early detection of ongoing or worsening ischemia allows prompt intervention. Continued ischemia can lead to extension of infarction and worsening shock.
3. Monitor cardiac biomarkers (troponin, CK-MB) as ordered. Trending cardiac biomarkers helps evaluate whether myocardial injury is ongoing or resolving. Rising levels indicate continued damage.
4. Collaborate with the healthcare team regarding reperfusion strategies:
  • Percutaneous coronary intervention (PCI)
  • Coronary artery bypass grafting (CABG)
  • Thrombolytic therapy (if PCI not available)
 Early coronary revascularization is the definitive treatment for cardiogenic shock due to acute myocardial infarction. Restoration of coronary blood flow improves myocardial function and survival.
5. Administer prescribed antiplatelet and anticoagulant medications:
  • Aspirin
  • P2Y12 inhibitors (clopidogrel, ticagrelor, prasugrel)
  • Heparin (unfractionated or low molecular weight)
 Antiplatelet and anticoagulant therapies prevent further thrombosis and maintain patency of coronary vessels, especially after revascularization.
6. Maintain oxygen saturation >94% to optimize myocardial oxygen delivery. Adequate arterial oxygenation ensures maximal oxygen content in the blood available for myocardial uptake, even with limited coronary flow.
7. Optimize hemoglobin levels:
  • Monitor complete blood count
  • Administer blood products as prescribed (target Hgb >8-10 g/dL)
 Hemoglobin is the primary oxygen carrier. Optimizing hemoglobin ensures adequate oxygen-carrying capacity, enhancing oxygen delivery to the myocardium.
8. Avoid excessive tachycardia and treat arrhythmias promptly:
  • Target heart rate 60-100 bpm
  • Administer antiarrhythmic medications as prescribed
 Tachycardia increases myocardial oxygen consumption and decreases diastolic filling time, reducing coronary perfusion. Arrhythmias can further compromise cardiac output and coronary blood flow.

Evaluation:

  • Monitor for signs and symptoms of myocardial ischemia
  • Assess hemodynamic parameters affecting coronary perfusion
  • Review ECG findings and cardiac biomarker trends
  • Document response to reperfusion strategies if implemented

6. Anxiety

Psychological Emotional

NANDA Definition: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response; a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat.

Related Factors:

  • Life-threatening crisis
  • Critical illness
  • Dyspnea
  • Pain
  • Fear of death
  • Unfamiliar environment (ICU)
  • Sensory overload
  • Powerlessness
  • Lack of knowledge about condition and procedures

Defining Characteristics:

  • Verbalized anxiety or fear
  • Restlessness
  • Increased heart rate
  • Increased respiratory rate
  • Increased blood pressure
  • Diaphoresis
  • Trembling
  • Facial tension
  • Focus on self
  • Excessive questioning or silence

Expected Outcomes:

  • Patient will demonstrate reduced anxiety as evidenced by:
    • Verbalization of feeling calmer
    • Decreased physical signs of anxiety
    • Use of effective coping strategies
    • Appropriate participation in care
    • Improved ability to rest
Nursing Interventions Rationale
1. Assess level of anxiety and contributing factors using appropriate assessment tools. Understanding the severity and specific triggers of anxiety allows for targeted interventions. Anxiety assessment provides baseline for evaluating effectiveness of interventions.
2. Establish a therapeutic relationship:
  • Demonstrate calm, confident approach
  • Use clear, concise communication
  • Provide consistent caregivers when possible
  • Address patient by preferred name
 A therapeutic nurse-patient relationship promotes trust and security. The nurse’s demeanor can either heighten or reduce patient anxiety. Consistency in caregivers reduces stress related to constantly explaining needs to different staff.
3. Provide information about procedures, treatments, and expected sensations:
  • Use simple language
  • Explain rationale for interventions
  • Verify understanding
 Knowledge and predictability reduce fear of the unknown. Understanding what to expect helps patients maintain a sense of control. Information should be provided in manageable amounts to avoid overwhelming the patient.
4. Create a calm environment:
  • Reduce unnecessary noise and alarms
  • Adjust lighting to promote comfort
  • Limit number of personnel and visitors as appropriate
  • Maintain privacy
 Environmental stimuli can heighten anxiety, especially in critical care settings. A calm, controlled environment promotes relaxation and reduces sensory overload.
5. Teach and assist with relaxation techniques:
  • Deep breathing exercises
  • Progressive muscle relaxation
  • Guided imagery
  • Distraction techniques
 Relaxation techniques activate the parasympathetic nervous system, countering the sympathetic response of anxiety. These techniques provide coping mechanisms the patient can use independently when anxiety increases.
6. Administer anxiolytic medications as prescribed, monitoring for effects and side effects. Pharmacological intervention may be necessary for severe anxiety. However, anxiolytics should be used cautiously in hemodynamically unstable patients as they may cause hypotension or respiratory depression.
7. Encourage family presence and participation in care as appropriate. Family provides emotional support and familiarity in the unfamiliar environment. Having trusted individuals nearby can significantly reduce anxiety for many patients.
8. Address spiritual needs:
  • Offer chaplain services if desired
  • Provide privacy for religious practices
  • Support use of meaningful religious/spiritual items
 Spiritual support can provide comfort and meaning during crisis. Addressing spiritual needs acknowledges the whole person and may help patients find strength and peace.

Clinical Consideration:

Anxiety increases sympathetic nervous system activation, which can increase heart rate, blood pressure, and myocardial oxygen demand—potentially worsening cardiac function in cardiogenic shock. Managing anxiety is not just for comfort but is physiologically important.

Evaluation:

  • Assess verbal and nonverbal indicators of anxiety
  • Monitor physiological parameters (heart rate, blood pressure, respiratory rate)
  • Evaluate effectiveness of coping strategies
  • Document response to interventions

7. Deficient Knowledge

Educational Cognitive

NANDA Definition: Absence or deficiency of cognitive information related to a specific topic.

Related Factors:

  • Lack of exposure to information
  • Unfamiliarity with information resources
  • Insufficient knowledge of condition
  • Cognitive limitations due to critical illness
  • Information misinterpretation
  • Insufficient time to learn
  • Anxiety interfering with learning

Defining Characteristics:

  • Verbalization of lack of understanding
  • Inaccurate follow-through of instructions
  • Inappropriate or exaggerated behaviors
  • Multiple questions
  • Expressed misconceptions
  • Lack of questions despite obvious knowledge deficits
  • Anxiety regarding unfamiliar procedures

Expected Outcomes:

  • Patient and/or family will demonstrate increased knowledge as evidenced by:
    • Verbalization of understanding of cardiogenic shock
    • Ability to explain rationale for treatments
    • Recognition of warning signs requiring immediate attention
    • Participation in decision-making about care
    • Demonstration of required skills for self-care
Nursing Interventions Rationale
1. Assess patient/family’s current level of understanding about:
  • Cardiogenic shock
  • Underlying cause
  • Treatment plan
  • Procedures and monitoring
 Assessment of existing knowledge provides foundation for individualized teaching. Identifying misconceptions and knowledge gaps allows for targeted education.
2. Determine readiness to learn and preferred learning style. Learning is most effective when the patient/family is receptive and information is presented in a way that matches their learning preferences. Acute illness and anxiety can impair learning ability.
3. Provide information in stages, starting with essential information:
  • Begin with immediate concerns
  • Use simple, clear language
  • Avoid medical jargon
  • Provide written materials to supplement verbal instruction
 Information presented in manageable amounts is easier to process and retain, especially during stress. Written materials allow for review and reinforcement of information.
4. Explain cardiogenic shock in simple terms:
  • Basic heart function
  • What happens in cardiogenic shock
  • Purpose of treatments
  • Expected recovery process
 Understanding the condition helps patients/families make sense of symptoms and treatments. Knowledge reduces fear and promotes cooperation with the treatment plan.
5. Explain purpose and function of equipment and procedures:
  • Monitoring devices
  • Intravenous lines and medications
  • Oxygen therapy
  • Mechanical circulatory support if applicable
 Understanding the purpose of unfamiliar equipment reduces anxiety. Knowledge about procedures helps set realistic expectations and increases cooperation.
6. Teach about medications:
  • Names and purposes
  • Administration schedules
  • Expected effects
  • Potential side effects
  • Side effects requiring immediate attention
 Medication knowledge is essential for adherence and safety. Understanding the purpose and expected effects of medications increases willingness to take them as prescribed.
7. Teach recognition of warning signs requiring immediate attention:
  • Chest pain
  • Shortness of breath
  • Lightheadedness
  • Palpitations
  • Decreased urine output
  • Swelling
 Early recognition of complications allows for prompt intervention. Patients/families need to know when and how to seek help quickly.
8. Use teach-back method to verify understanding:
  • Ask patient/family to explain information in their own words
  • Have them demonstrate skills if appropriate
  • Correct misunderstandings immediately
  • Reinforce accurate information
 Teach-back confirms actual comprehension rather than passive listening. It identifies areas needing clarification or reinforcement and allows for immediate correction of misunderstandings.

Evaluation:

  • Assess verbal understanding through teach-back
  • Observe demonstration of required skills
  • Monitor for questions indicating comprehension or confusion
  • Document educational interventions and patient/family response
  • Identify topics requiring additional teaching

8. Risk for Electrolyte Imbalance

Risk Metabolic

NANDA Definition: Vulnerable to changes in serum electrolyte levels, which may compromise health.

Risk Factors:

  • Renal dysfunction due to hypoperfusion
  • Diuretic therapy
  • Acid-base imbalances
  • Medication effects (vasopressors, inotropes)
  • Fluid shifts
  • Compromised regulatory mechanisms
  • Tissue hypoxia
  • Gastrointestinal losses (vomiting)

Expected Outcomes:

  • Patient will maintain electrolyte levels within normal limits as evidenced by:
    • Laboratory values within normal range
    • Absence of symptoms of electrolyte imbalances
    • Normal cardiac rhythm
    • Stable neuromuscular function
Nursing Interventions Rationale
1. Monitor serum electrolyte levels:
  • Potassium
  • Sodium
  • Calcium
  • Magnesium
  • Phosphorus
  • Chloride
 Regular monitoring allows early detection of imbalances before they become symptomatic. Trending values helps evaluate treatment effectiveness and disease progression.
2. Assess for clinical manifestations of electrolyte imbalances:
  • Potassium: Arrhythmias, ECG changes, muscle weakness
  • Sodium: Mental status changes, seizures, edema
  • Calcium: Tetany, prolonged QT, cardiac irritability
  • Magnesium: Tremors, arrhythmias, seizures
 Clinical manifestations may appear before laboratory abnormalities become severe. Early recognition allows prompt intervention to prevent complications.
3. Monitor continuous cardiac monitoring for dysrhythmias related to electrolyte imbalances. Electrolyte abnormalities (particularly potassium, calcium, and magnesium) can cause serious cardiac arrhythmias. Continuous monitoring allows immediate detection of these complications.
4. Monitor renal function through:
  • Urine output
  • BUN and creatinine
  • Estimated GFR
 Renal dysfunction in cardiogenic shock impairs electrolyte excretion and regulation. Medication dosing may need adjustment based on renal function.
5. Administer electrolyte replacement as prescribed:
  • Follow guidelines for safe administration rates
  • Use appropriate diluents and concentrations
  • Monitor for infusion site reactions
 Proper administration techniques ensure safe replacement of electrolytes. Certain electrolytes (e.g., potassium, calcium) require specific dilution and infusion rates to prevent complications.
6. For patients on diuretics:
  • Monitor electrolytes more frequently
  • Observe for increased losses
  • Anticipate need for supplementation
 Diuretics (especially loop diuretics) cause significant electrolyte losses, particularly potassium and magnesium. Proactive monitoring and replacement prevent symptomatic deficiencies.
7. Pay particular attention to potassium levels:
  • Maintain K+ between 4.0-5.0 mEq/L
  • Replace K+ when <4.0 mEq/L
  • Ensure adequate magnesium levels for K+ replacement
 Hypokalemia increases risk of arrhythmias, which are poorly tolerated in cardiogenic shock. Magnesium deficiency makes potassium replacement less effective and more difficult to maintain.
8. Monitor acid-base status through ABGs and address imbalances. Acid-base disorders affect electrolyte distribution and function. Acidosis can cause hyperkalemia by shifting potassium out of cells, while respiratory alkalosis can cause symptomatic hypocalcemia.

Critical Electrolyte Values Requiring Immediate Intervention:

  • Potassium: <2.5 mEq/L or >6.0 mEq/L
  • Sodium: <125 mEq/L or >155 mEq/L
  • Calcium (ionized): <3.5 mg/dL or >6.0 mg/dL
  • Magnesium: <1.0 mg/dL or >4.0 mg/dL

Evaluation:

  • Monitor laboratory values for electrolytes
  • Assess for signs and symptoms of electrolyte imbalances
  • Monitor cardiac rhythm for electrolyte-related dysrhythmias
  • Document response to electrolyte replacement
  • Modify replacement protocols based on patient response

9. Activity Intolerance

Functional Mobility

NANDA Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Related Factors:

  • Decreased cardiac output
  • Imbalance between oxygen supply and demand
  • Bed rest/immobility
  • Generalized weakness
  • Sedating medications
  • Poor nutritional status
  • Fluid volume overload

Defining Characteristics:

  • Abnormal heart rate or blood pressure in response to activity
  • Dyspnea on exertion
  • Exertional discomfort or fatigue
  • Weakness
  • Decreased oxygen saturation with activity
  • Verbal report of fatigue
  • Inability to perform activities of daily living

Expected Outcomes:

  • Patient will demonstrate improved activity tolerance as evidenced by:
    • Stable vital signs during and after activity
    • Absence of dyspnea, chest pain, or excessive fatigue with activity
    • Gradual increase in activity level as condition improves
    • Participation in self-care activities at level of ability
    • Verbalization of increased energy
Nursing Interventions Rationale
1. Assess baseline activity tolerance and functional capacity:
  • Prior activity level
  • Current limitations
  • Vital sign response to minimal activity
 Establishing baseline helps set realistic goals and measure progress. Understanding previous functional capacity aids in developing an appropriate activity progression plan.
2. Monitor vital signs before, during, and after activity:
  • Heart rate (should return to baseline within 5 minutes)
  • Blood pressure (should not drop >20 mmHg)
  • Respiratory rate
  • Oxygen saturation (should remain >90%)
 Vital sign changes with activity provide objective data about cardiovascular response and tolerance. Excessive changes indicate activity beyond current capacity and potential for harm.
3. Observe for signs of activity intolerance:
  • Dyspnea
  • Chest pain or discomfort
  • Dizziness
  • Pallor or cyanosis
  • Diaphoresis
  • Excessive fatigue
 Early recognition of signs of intolerance prevents adverse events. These symptoms indicate the activity level exceeds the patient’s current cardiovascular capacity.
4. Implement a progressive activity plan appropriate to hemodynamic status:
  • Phase 1: Passive range of motion, in-bed positioning
  • Phase 2: Active range of motion, dangling legs at bedside
  • Phase 3: Seated position in chair, ambulation with assistance
  • Phase 4: Progressive ambulation
 Gradual progression prevents deconditioning while respecting cardiovascular limitations. Each phase builds capacity for the next level. Even minimal activity helps prevent complications of immobility.
5. Schedule activities to allow for adequate rest periods:
  • Plan activities when energy levels are highest
  • Alternate activity with rest
  • Coordinate activities with medication schedule
 Rest periods allow for energy conservation and recovery between activities. Timing activities when medications are at peak effectiveness can improve tolerance.
6. Collaborate with physical therapy for individualized exercise plan:
  • Cardiac rehabilitation principles
  • Energy conservation techniques
  • Breathing exercises
 Physical therapy provides expertise in safe mobilization of critically ill patients. A structured program helps prevent deconditioning while respecting physiological limitations.
7. Provide assistance with activities of daily living based on tolerance:
  • Encourage self-care to tolerance
  • Assist with activities exceeding capacity
  • Provide assistive devices as needed
 Balancing assistance with independence promotes self-efficacy while preventing excessive exertion. Self-care activities provide functional exercise within patient’s capacity.
8. Implement measures to reduce oxygen demand:
  • Maintain adequate oxygenation
  • Optimize hemoglobin
  • Maintain normothermia
  • Provide adequate nutrition
 Optimizing oxygen delivery and reducing oxygen demand improves activity tolerance. Addressing factors that increase metabolic demand allows energy to be directed toward meaningful activities.

Clinical Pearl:

Early mobilization, even during critical illness, has been shown to reduce complications, shorten ICU and hospital length of stay, and improve functional outcomes. However, activity must be carefully matched to the patient’s hemodynamic stability and physiological reserves.

Evaluation:

  • Monitor vital sign response to activity
  • Assess patient’s subjective report of fatigue or dyspnea
  • Document activity tolerance and progression
  • Evaluate effectiveness of rest periods between activities
  • Adjust activity plan based on patient’s response

10. Excess Fluid Volume

Fluid Balance Hemodynamic

NANDA Definition: Increased isotonic fluid retention.

Related Factors:

  • Decreased cardiac output
  • Decreased left ventricular function
  • Increased pulmonary capillary wedge pressure
  • Compromised regulatory mechanisms
  • Excessive fluid administration
  • Excessive sodium intake
  • Activation of renin-angiotensin-aldosterone system
  • Renal hypoperfusion

Defining Characteristics:

  • Pulmonary congestion/edema
  • Crackles/rales
  • Dyspnea
  • Elevated central venous pressure
  • Elevated pulmonary capillary wedge pressure
  • Jugular vein distention
  • S₃ heart sound
  • Peripheral edema
  • Weight gain
  • Decreased urine output
  • Pleural effusion
  • Hepatomegaly

Expected Outcomes:

  • Patient will demonstrate improved fluid balance as evidenced by:
    • Clear lung sounds
    • Reduced peripheral edema
    • Improved oxygenation
    • Decreased CVP and PCWP to normal range
    • Adequate urine output
    • Stable or reduced weight toward baseline
    • Resolution of JVD
Nursing Interventions Rationale
1. Assess fluid status:
  • Daily weight (same time, clothing, scale)
  • Intake and output every 1-2 hours
  • Lung sounds every 2-4 hours
  • Presence and degree of peripheral edema
  • Jugular venous distention
 Accurate assessment of fluid status guides treatment decisions. Daily weight is one of the most reliable indicators of fluid changes (1 kg = approximately 1 L of fluid). Monitoring trends helps evaluate treatment effectiveness.
2. Monitor hemodynamic parameters:
  • Central venous pressure
  • Pulmonary capillary wedge pressure
  • Cardiac output/index
 Hemodynamic monitoring provides objective data about intravascular volume and cardiac function. Elevated filling pressures indicate fluid overload and guide diuretic therapy.
3. Administer diuretics as prescribed:
  • Loop diuretics (furosemide, bumetanide)
  • May require continuous infusion
  • Monitor response and adjust as needed
 Diuretics promote fluid removal through increased urine output. Loop diuretics reduce preload and pulmonary congestion. Continuous infusion may be more effective than bolus dosing in resistant fluid overload.
4. Implement fluid restrictions as ordered. Limiting fluid intake helps reduce total body water when combined with diuretics. This is especially important when diuretic response is diminished.
5. Monitor electrolytes closely, particularly:
  • Potassium
  • Sodium
  • Magnesium
 Diuretic therapy can cause significant electrolyte abnormalities. Hypokalemia and hypomagnesemia increase risk of arrhythmias. Sodium depletion can affect diuretic efficacy.
6. Position patient to optimize respiratory function:
  • Elevate head of bed 30-45°
  • Support arms with pillows
  • Position to reduce dependent edema
 Proper positioning reduces pulmonary congestion and work of breathing. Elevating extremities promotes venous return and reduces peripheral edema.
7. Administer supplemental oxygen as needed to maintain SpO₂ >94%. Pulmonary edema impairs gas exchange, requiring supplemental oxygen. Maintaining adequate oxygenation reduces respiratory distress and supports cardiac function.
8. For severe pulmonary edema, prepare for additional interventions:
  • Non-invasive positive pressure ventilation
  • Intravenous nitrates
  • Possible intubation and mechanical ventilation
 Severe pulmonary edema may require these interventions to support oxygenation and reduce preload. NIPPV improves oxygenation and reduces work of breathing. Nitrates reduce preload and improve pulmonary congestion.

Monitor for Signs of Diuretic Response:

  • Urine output increase within 20-30 minutes of IV loop diuretic administration
  • Net negative fluid balance
  • Decreased weight
  • Improved lung sounds
  • Decreased peripheral edema
  • Improved oxygenation

Evaluation:

  • Monitor daily weights and trends
  • Assess lung sounds for improvement
  • Evaluate hemodynamic parameters
  • Monitor fluid balance (intake vs output)
  • Assess for relief of symptoms (dyspnea, orthopnea)
  • Document response to diuretic therapy

11. Altered Nutrition: Less than Body Requirements

Nutritional Metabolic

NANDA Definition: Intake of nutrients insufficient to meet metabolic needs.

Related Factors:

  • Decreased appetite
  • Nausea
  • Fatigue
  • Dyspnea
  • Altered taste sensation due to medications
  • Increased metabolic demands during critical illness
  • Malabsorption related to gastrointestinal hypoperfusion
  • Inability to ingest food due to intubation
  • Psychological factors (anxiety, depression)

Defining Characteristics:

  • Food intake less than recommended daily allowance
  • Weight loss
  • Decreased muscle mass/tone
  • Weakness and fatigue
  • Altered laboratory values (albumin, transferrin, lymphocytes)
  • Poor wound healing
  • Reduced immunity
  • Pale mucous membranes

Expected Outcomes:

  • Patient will maintain adequate nutritional status as evidenced by:
    • Weight stabilization or appropriate weight gain
    • Intake meeting calculated caloric needs
    • Normalized laboratory values
    • Improved strength and energy
    • Wound healing if applicable
    • Adequate hydration
Nursing Interventions Rationale
1. Conduct nutritional assessment:
  • Current weight and BMI
  • Recent weight changes
  • Usual dietary intake and preferences
  • Laboratory values (albumin, prealbumin, transferrin)
  • Factors affecting intake
 Comprehensive assessment identifies baseline nutritional status and specific deficits. This information guides appropriate nutritional interventions. Critical illness increases nutritional requirements while often impairing intake.
2. Collaborate with dietitian to determine:
  • Caloric and protein requirements
  • Appropriate diet consistency
  • Need for nutritional supplements
  • Enteral or parenteral nutrition needs
 Dietitians have specialized expertise in calculating nutritional needs in critical illness. Individualized nutritional plans optimize healing and recovery while respecting dietary restrictions (e.g., sodium restriction for heart failure).
3. For oral intake:
  • Provide small, frequent meals
  • Ensure comfortable positioning
  • Manage symptoms affecting intake (nausea, pain)
  • Offer nutrient-dense foods
  • Provide oral supplements as prescribed
 Small, frequent meals are better tolerated than large meals, especially with limited cardiac reserve. Symptom management improves intake and comfort. Nutrient-dense foods and supplements maximize nutritional value of limited intake.
4. For patients unable to maintain adequate oral intake:
  • Initiate enteral nutrition within 24-48 hours if feasible
  • Follow feeding protocols for rate advancement
  • Monitor for feeding intolerance
  • Elevate head of bed to 30-45° during feeding
 Early enteral nutrition supports gut integrity and immune function. Proper positioning and protocol adherence reduce risk of aspiration and complications. Enteral nutrition is preferred over parenteral when the gastrointestinal tract is functional.
5. For parenteral nutrition if indicated:
  • Adhere to strict aseptic technique
  • Monitor glucose levels frequently
  • Prevent line complications
  • Monitor for metabolic complications
 Parenteral nutrition may be necessary when enteral route is contraindicated. It carries higher risks of infection, metabolic complications, and is less physiologic than enteral nutrition. Careful monitoring minimizes these risks.
6. Monitor laboratory values related to nutrition:
  • Electrolytes
  • Glucose
  • Albumin
  • Prealbumin
  • Nitrogen balance studies
 Regular laboratory monitoring assesses nutritional status and detects complications. Trending values helps evaluate effectiveness of nutritional support. Electrolyte abnormalities can occur with refeeding syndrome.
7. Administer prescribed medications that may improve appetite or digestion:
  • Antiemetics
  • Prokinetic agents
  • Appetite stimulants if ordered
 Medication therapy can address factors limiting nutrition intake. Antiemetics improve tolerance of meals. Prokinetic agents can improve absorption in patients with gastroparesis due to critical illness.
8. Document nutritional intake: