Is this patient having Hypovolemic shock or Cardiogenic Shock or both？

Published

This patient has been recovering in the ICU for the last 2-days following heart bypass surgery. He had medical history of Type II DM, IHD, hypertension and obesity. Obs are BP 95/70 RR 28 Temp 35.9 HR 140 and the urine output for the last 4-hours is 20mL.

These two type of shocks have the same sign and symptoms.I don't know which one.Anyone got some ideas?

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
This patient has been recovering in the ICU for the last 2-days following heart bypass surgery. He had medical history of Type II DM, IHD, hypertension and obesity. Obs are BP 95/70 RR 28 Temp 35.9 HR 140 and the urine output for the last 4-hours is 20 mL.

These two type of shocks have the same sign and symptoms.I don't know which one.Anyone got some ideas?

\

Welcome to AN! We are the largest online nursing community. we will help with homework but we won't so it for you. We will lead you in to right direction and allow you to get the answer. It is helpful if you show us what you think and at what point of school you are in so we can customize the answers better. Tell us......What is your first "gut" reaction and why.

Ok.....now, To figure out which, there is essential information you need to know about your patient. This is a process that will become second nature the longer you are a nurse.

What are your primary disease pathophysiology. Know Type II diabetes. Now what IHD (Ischemic Heart Disease) is and how it affects the body. Know that CAD causes the ischemia that leads to ischemic heart disease. What is HTN and what it does to the body.

CAD

Medscape: Medscape Access

Myocardial Infarction

HTN

Medscape: Medscape Access

Then what are the symptoms/pathophysiology of Hypovolemic shock and cardiogenic shock. What is the factor that separates the two types of shock? What are the patients labs like the H&H? What is the chest tube output? Is this patient bleeding? Is the patient pale, diaphorectic If this is a care plan you need to find this information.

For advanced assessment you would need to know the cardiac output, cardiac index, and stroke volume.

Hypovolemic shock

Medscape: Medscape Access

Cardiogenic shock

Medscape: Medscape Access

Medscape requires a simple registration but it is a reliable source and excellent resource/reference and IT IS FREE....no strings.

Then you need to know about the procedure CABG. What is CABG? What happens with CABG? What are the complications with CABG? What do you look for post op?

Coronary artery bypass grafting

Medscape: Medscape Access

Now if this is just a question......you still need to know the information above because it is apart of the critical thinking that occurs in the decision making process.

The answer to the question can always be a debate and usually the clues to the answer is in the question. The question mentions that the patient is 2 days post op. In the real world this patient will have had lab work done and you would know if the patient is bleeding by looking at chest tube drainage. You would ask the patient if they are having chest pain, you would listen to the heart tones order stat labs, EKG and CXR (under the standing orders for post op heart)

So..... The patient is 2 days post op and the patient becomes hypotensive and tachycardic and tachypnic. They are not c/o acute chest pain (acording to the question) which may rule out a massive heart attack. The recent surgery may have nicked something else or the patient is leaking/bleeding from a newly placed graft. The B/P is 90/70...any clues?

Which type of shock do you think it is?

Up Vote Up Vote ×

Esme12 gave you a great start. Did the patient have a central line or a PA line in place? If so, do you have the CVP, SVR, PAWP, PA pressure, etc? These numbers are a great indicator of heart function, hydration status, and shock state. If you do not have these numbers, it is still possible to determine the shock state this patient is in.

As Esme12 said, the patient had no complaints of chest pain. You do not mention complaints of shortness of breath, nausea, vomiting, neck pain, back pain, jaw pain, etc. Nothing in this scenario seems to indicate cardiac ischemia or MI. As Esme12 also said, you could look at the chest tube drainage, as well as drainage from any other drains they may have in place (such as hemovacs, JPs, or Cardiopats) to see if the drainage was excessive.

CABG (coronary artery bypass grafting) is a big deal, and bleeding can and does happen. What labs would you expect to come back abnormal if this patient was actively bleeding? What kind of assessment are you going to do? What treatment plan do you foresee for this patient? Would you do an EKG to rule out cardiac involvement? What lab studies look at muscle damage, and which labs look specifically at cardiac muscle damage? Would you order these labs, too?

If I had to speculate, I would say that this sounds like hypovolemic shock more so than cardiogenic shock.

Up Vote Up Vote ×

There is something unique to cardiogenic shock, find this golden ticket and ye shall have the answer.......

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

mindlor......what might that be????

Up Vote Up Vote ×
mindlor......what might that be????

High CVP is characteristic of cardiogenic shock, not so in other types of shock.......

was gonna leave this for the OP to research but being that you asked......

Up Vote Up Vote ×

The best answer truly would be that from the information provided by the OP, there would not be a clear way to differentiate between hypovolemic shock and cardiogenic shock......

Pt is in the ICU so taking a quick squiz at CVP or PAWP should be fairly doable....

If we know that the intravascular fluid levels are adequate, but the cardiac index is still low, say less than 2.2 L/min, then itts time to start thinking cardiogenic yes?

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Yes but The CVP and PCWP is not enough information, per se, to indicate cardiogenic shock. A Cardiac output would be key as well....but there is something very telling in this scenario itself, low B/P and cardiac surgery, that is the subtle KEY....can you find it?

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

hint: something very specific to the cardiac workload itself.

Up Vote Up Vote ×

Well, the best clinical indicator of cardia output is urine output. 20 mL over 4 hours is very poor.

However, from just the info provided it cannot be ascertained if this is caused by hypovolemia or by poor CO....

It would require reading into the scenario......

But yes, recent cadiac surgery is an issue......

We still really really really need to know that CVP and PAWP in my very humble opinion ;)

Up Vote Up Vote ×

Can I ask what might be a really stupid question? I'm about to start nursing school in May and I appreciate all the great direction that is given here. I know very, very little about cardiogenic shock. However, what I'm wondering is this: if a patient has been icu post op for 2 days, they are surely getting IV fluids, right? If the patient has hypovolemic shock due to internal bleeding, there would be dehydration signs in the pt's tissues, no? And if the patient had cardiogenic shock due to decreased capacity of the heart, the tissues would potentially show edema, would they not? The fluid coming in through the IV has to go somewhere doesn't it? Any comments on my (very inexperienced, newbie) thinking process would be greatly appreciated.

Up Vote Up Vote ×

And by tissues, I don't exclusively mean peripheral tissues, for cardiogenic shock, I was thinking maybe pulmonary???

Up Vote Up Vote ×
+ Join the Discussion