Cardiogenic shock is, by definition, circulatory failure due to a cardiac dysfunction resulting from right ventricular, left ventricular or biventricular failure.1 Cardiogenic shock occurs in 5%–7% of patients who suffer an acute myocardial infarction (AMI), being more common in those patients who have suffered an AMI with elevated ST.2

The European Society of Cardiology (ESC) guidelines contain a section exclusively devoted to cardiogenic shock and its treatment.3

Treatment for cardiogenic shock includes the use of circulatory support therapies when medical treatment has been insufficient and these can offer a bridge to decision making as they allow time to assess the patient’s situation and to consider the different therapeutic options available.3,4

Another serious complication that may occur in the haemodynamic lab treating the AMI, is allergic reaction to the iodinated contrast, leading to anaphylactic shock.5,6

The clinical case we present combines the 2 complications in the case of a 40-year-old patient who suffered a mixed cardiogenic and anaphylactic shock, requiring circulatory ventricular assist support.

The aim was to show a clinical case with presentation of a personalised care plan using NANDA-NOC-NIC7 taxonomy.

We present a clinical case of a 40-year-old woman, with a history of Hodgkin’s lymphoma in 2016, who was transferred by the emergency medical services (EMS) to our centre for AMI in Killip class I. Emergency coronary angiography via right radial route was performed in which coronary artery disease of the anterior descending coronary artery was observed. Coinciding with the infusion of iodinated contrast medium the patient presented with tachycardia and hypotension, followed by an episode of bronchospasm. The patient was diagnosed with anaphylactic and cardiogenic shock and adrenaline, corticosteroids and antihistamines were administered.

She then presented with cardiorespiratory arrest (CRA) due to ventricular fibrillation and advanced cardiopulmonary resuscitation (CPR) was started, recovering spontaneous circulation after 20 min. A cardiac ultrasound was performed showing severe ventricular dysfunction with an ejection fraction of 20%.

A few minutes later she suffered a second CRA and the cardiovascular surgery team was contacted. It was decided to proceed with the implantation of an Extracorporeal Membrane Oxygenation venous artery (ECMO-VA) and an intra-aortic balloon pump (IABP) in the haemodynamics laboratory for subsequent revascularisation with thromboaspiration and balloon dilatation of the anterior descending and circumflex arteries.

The patient presented with critical ischaemia of the lower extremities due to the presence of the arterial cannula and the balloon in both femoral arteries. It was therefore decided to take her to the operating theatre for conversion to a central left ventricular assist device (LVAD) (Fig. 1) and repair of both femoral arteries. Once the procedure was completed, she was transferred to the intensive care unit (ICU) with an open chest for better clinical management.

Figure 1.

CentriMag-Levitronix®.

(0.21MB).

During her stay in the ICU she required 3 sternal revision due to bulging smarck and bleeding from the mediastinal drains, support with vasoactive drugs and support, as mentioned above, with a LVAD.

After 72 h the patient remained haemodynamically stable, the vasoactive support could be reduced and the LVAD was withdrawn.

When the patient was admitted to our ICU a nursing assessment was carried out 6 h after admission, in keeping with the Virginia Henderson 14-need model:

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  Breathe normally: orotracheal intubation connected to invasive mechanical ventilation (IMV) in volume control mode (VC); FiO2: .55; PEEP: 5. Active humidification, secretions with haematic debris through the endotracheal tube.

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  Eat and drink adequately: Carrier of Salem nasogastric tube in intermittent aspiration, moderate bilious debit. Carrier of parenteral nutrition administered by central venous catheter. Abdomen soft and depressible.

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  Eliminate body wastes: bladder catheter wearer, correct urine output with clear urine. Wearing a nappy as a precaution.

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  Move and maintain desirable postures: bedridden patient. Supine decubitus with pillow on the feet to avoid clubfoot. Barthel index 0 (totally dependent).

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  Sleep and rest: sedoanalgesia con propofol and remifentanil.

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  Select suitable clothes – dress and undress: dependent due to physical immobility and sedation.

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  Maintain body temperature: afebrile, heat transfer through LVAD heater and forced air warming blanket. Lower extremities pale and cold with pulses present but weak.

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  Keep the body clean and well groomed and protect the skin: daily hygiene of the bedridden critically ill patient, LVAD carrier, totally dependent. Patient with open chest and surgical wounds (insertion of ECMO and IABP cannulas). Skin hydration and application of hyperoxygenated fatty acids to prevent pressure ulcers. Normohydrated skin.

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  Avoid dangers in the environment and avoid injuring others: use of bedrails, identification bracelet. Measures to prevent infection of catheters and surgical wounds. Compliance with Zero Pneumonia and Zero Bacteraemia protocols.

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  Communicate with others: incapable of communicating. Richmond Agitation Sedation Scale (RASS) −5: very deep sedation.

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  Worship according to one’s faith: agnostic. No advance directives.

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  Work in such a way that there is a sense of accomplishment: patient active before admission.

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  Play or participate in various forms of recreation: active social life, rides a motorcycle at the week-ends.

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  Learn, discover or satisfy curiosity: the patient was attending courses on painting and English in her free time.

For the development of the care plan, the nursing diagnoses (ND) according to the NANDA taxonomy and the potential or real collaboration problems that the patient presented during her stay in the ICU were described. The development of the standardised NANDA-NOC-NIC language in the clinical case presented allowed us to methodologically organise the nursing work, facilitating recording and standardising practice.

The AREA model was used to detect the ND principles (Fig. 2). This resulted in 6 principal diagnoses, 2 of which were directly derived from the LVAD.

Figure 2.

Nursing clinical reasoning network, according to the AREA model.

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Table 1 contains the care plan with the ND (NANDA), the objectives (NOC) and interventions (NIC) with outcome and activity markers.

Table 2 describes the collaboration problems and potential complications.

When care in the cardiac ICU had terminated and prior to transfer to the coronary ICU, an assessment of outcomes obtained (OO) was made. The 5-point Likert scale was used for assessment of NOC outcomes.

The occurrence of anaphylactic shock in a patent with Killip I infarction aggravated the situation causing mixed shock, developing into treatment-refractory CRA, necessitating the implantation of an ECMO in situ. Acute arterial ischaemia of both lower extremities made it necessary to implant a LVAD in order to remove the ECMO and IABP.

Due to this previous situation the patient was admitted to our ICU in an unstable condition and an individualised care plan was drawn up using care plans for patients on ventricular support as a guide.8

Among the main limitations which arose was the difficulty in movements due to the open chest. It was not possible to put the patient on her side to assess her skin periodically and prevent pressure ulcers forming on her back and sacral region. However, we placed special emphasis on ensuring the patient’s parenteral nutrition and keeping the air mattress anti-bedsore-mode activated.

When the care plan was created we believed it important to consider constipation as a potential problem since this is a highly important need which is often ignored in the ICU. Sixty three per cent of patients admitted to the ICU suffer from constipation, which is why we wanted to stress the importance of making nursing professionals aware of the relevance of a correct elimination pattern.9

We wish to indicate that on review of the literature to support the creation of the care plan, one difficulty we encountered was that there were no similar articles to be found with which to contrast our care plan with and we found no NIC relating to care of the patient with a sternal aperture. Further research is needed and analysis of nursing care cases according to the NANDA-NOC-NIC taxonomy in this type of patient.

Application of nursing care using standard taxonomies allows us to assess patient progress at any time and the effectiveness of nursing activity, ensuring quality care. Knowledge of techniques and anticipation of real or potential problems helped to resolve this extremely urgent situation to achieve patient stability. We wish to stress the responsibility of the nursing personnel since nursing activities are essential for good development of care.

The authors declare they have not received any financing for completing this study.

The authors have no conflict of interest to declare.