115-NCLEX-RN Review Made Incredibly Easy, Fifth Edition (Incredibly Easy...

Polish up on client care 41

emergency cart with a defibrillator at the bedside. Make sure the equipment is turned on and ready for immediate use to avoid treatment delay. Position the client at a 45- to 60-degree angle. Connect the precordial ECG lead to the hub of the aspiration needle with an alligator clamp and connecting wire. When the needle touches the myocardium during fluid aspira-tion, an ST-segment elevation or premature ventricular contractions will be seen. Moni-toring the clients ECG ensures accuracy of the procedure and helps prevent complications. Monitor blood pressure and CVP during and after pericardiocentesis to monitor for complications such as hypotension, which may indicate cardiac chamber puncture. Infuse I.V. solutions to maintain blood pressure. Watch for a decrease in CVP and a concomitant rise in blood pressure, which indicate relief of cardiac compression. Watch for complications of pericardiocen-tesis, such as VF, vasovagal response, and coronary artery or cardiac chamber puncture, to prevent or rapidly treat crisis. Closely monitor ECG changes, blood pressure, pulse rate, level of consciousness, and urine output to detect signs of decreased cardiac output.

If the client needs a thoracotomy Explain the procedure to the client. Tell him what to expect postoperatively (chest tubes, chest tube drainage system, administration of oxygen). Teach him how to turn, deep-breathe, and cough to prevent post-operative complications and relieve the clients anxiety. Give antibiotics to prevent or treat infection and protamine sulfate or vitamin K as needed to prevent hemorrhage. Postoperatively, monitor critical parame-ters, such as vital signs and ABG levels, and assess heart and breath sounds to detect early signs of complications such as reaccumulation of fluid. Give pain medication as needed to alleviate pain and promote comfort. Maintain the chest tube drainage system and be alert for complications, such as hem-orrhage and arrhythmias, to prevent further decompensation.

Teaching topics Explanation of the disorder and treatment plan Medications and possible adverse effects Alerting the nurse if condition worsens

Cardiogenic shock

Cardiogenic shock occurs when the heart fails to pump adequately, thereby reducing cardiac output and compromising tissue perfusion.

Heres how cardiogenic shock progresses: Decreased stroke volume results in increased left ventricular volume. Blood pooling in the left ventricle backs up into the lungs, causing pulmonary edema. To compensate for a falling cardiac output, heart rate and contractility increase. These compensating mechanisms increase the demand for myocardial oxygen. An imbalance between oxygen supply and demand results, increasing myocardial ischemia and further compromising the hearts pumping action.

CAUSES Advanced heart block Cardiomyopathy Heart failure MI Myocarditis Papillary muscle rupture

ASSESSMENT FINDINGS Anxiety, restlessness, disorientation, and confusion Cold, clammy skin Crackles in lungs Hypotension (systolic pressure below 90 mm Hg) Narrow pulse pressure Jugular vein distention Oliguria (urine output of less than 30 ml/hour) Third (S3) and fourth (S4) heart sounds Tachycardia or other arrhythmias Tachypnea, hypoxia Weak, thready pulse

A post-MI client exhibits

cold, clammy skin; hypotension; oliguria;

and tachycardia. Hmmmm. Probably

adds up to cardiogenic shock.

313419NCLEX-RN_Chap03.indd 41313419NCLEX-RN_Chap03.indd 41 4/8/2010 7:01:42 PM4/8/2010 7:01:42 PM

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