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A.

General information

1. Hypovolemic shock is an emergency condition in which severe blood and fluid loss makes the heart unable
to pump enough blood to the body. This type of shock can cause many organs to stop working. 2. Hypovolemic shock reduces CO and causes inadequate tissue perfusion from loss of circulating blood volume. 3. Inadequate tissue perfusion resulting from markedly reduced circulating volume. 4. Surgical patient’s are at high risk because of blood loss intraoperatively and trauma from the manipulation of body tissue. B. Causes 1. 3. 4. Hemorrhage Dehydration Trauma

2. Burns

C. Assessment findings 1. 2. 3. 4. 5. 6. 7. 8. 9. Systolic blood pressure less than 90 mm Hg or 30 mm Hg less than baseline values Rapid weak pulse Dyspnea Tachypnea Cool, clammy skin Pallor Extreme thirst Irritability Urine output less than 30mL/hr

D. Diagnostic test findings 1. 2. 3. 4. Chest X-ray: pulmonary lesions and areas of atelectasis ABG measurements: respiratory alkalosis progressing to combined respiratory and metabolic acidosis; hypoxemia Serum chemistries: increased BUN, alkaline phosphatase, creatinine, lactate, and potassium levels; decreased HCO3, and albumin levels CBC: increased hematocrit (HCT) levels

E. Patient care management goal: restore the circulating blood volume 1. 2. 3. 4. 5. 6. 7. Assess and document continuous ECG rhythm; vital signs; mental status; heart, lung, and bowel sounds; urine output; and any signs and symptoms indicating changes in these parameters Administer fluids (lactated Ringer’s solution or normal saline solution) to correct fluid deficit Obtain ABG measurements and monitor for hypoxemia and acid-base imbalance; monitor SaO2 with a pulse oximeter If a pulmonary artery catheter is in place, assess the patient’s fluid volume and document CVP, PAP, PAWP, CO, and SVR as ordered Weigh the patient daily, at the same time and on the same scale with patient wearing the same amount of clothing, to evaluate fluid balance Administer oxygen at a flow rate based on the patient’s clinical condition to relieve ischemia If gas exchange is inadequate, prepare the patient and equipment for intubation

Active bleeding or rupture of internal organs. Stage III occurs when 30% to 40% of the circulating volume. or up to 1500 mL of blood. Stage II occurs when 15% to 30%. metabolism shifts from aerobic to anaerobic pathways. Significant hypovolemic shock ( 40% loss of circulating volume) lasting several hours or more is associated with a fatal outcome. lactic acid accumulates in the tissues. and they cannot accomplish the removal of carbon dioxide. such as the bowel or the fallopian tube when caused by an ectopic pregnancy.Hypovolemic shock results from a decreased effective circulating volume of water. and multiple organ dysfunction syndrome. A significant loss of greater than 30% of circulating volume results in a decrease in venous return. External. or least 2000 mL of blood. can quickly result in hypovolemia even without obvious bleeding. When there is insufficient oxygen available to the cells. diminishes cardiac output and decreases perfusion to vital organs and causes the symptoms that are associated with shock. is lost. cerebrovascular accident. The most severe form of hypovolemic/ hemorrhagic shock is stage IV. In this process. The loss of circulating volume can result from a number of conditions. Hemorrhage caused by active blood loss that results from trauma is a frequent source of hypovolemia. the tissues do not receive adequate glucose. sudden blood loss resulting from penetrating trauma and severe gastrointestinal bleeding are common causes of hemorrhagic shock. Profound . In addition. if left uncorrected. which in turn. disseminated intravascular coagulation. plasma. death. acute renal failure. of the circulating volume is lost. The American College of Surgeons separates hypovolemic/hemorrhagic shock into four classifications: Stage I occurs when up to 15% of the circulating volume. Complications of hypovolemic shock include adult respiratory distress syndrome. or from 1500 to 2000 mL of blood. These patients often exhibit few symptoms because compensatory mechanisms support bodily functions. and the patient develops metabolic acidosis. This disruption in normal tissue metabolism results initially in cellular destruction and. These patients have subtle signs of shock. This patient has lost more than 40% of circulating volume. or approximately 750 mL of blood. but vital signs usually remain normal. is lost. This patient looks acutely ill. and is at risk for exsanguination. sepsis. or whole blood and is the most common type of shock in adults and children.

Percuss the chest and lung fields for the presence of fluid. In addition. and early management merge together into the primary survey. depending on the phase of of hypovolemic shock. agitation. the history. delayed . emergency medical personnel. Generally. rapid pulses.decreases in circulating fluid volume can be caused by the plasma shifts seen in burns and ascites. Other sources of hypovolemia include decreases in fluid intake (dehydration) and increases in fluid output (vomiting. or peritonitis. and decreased urinary output. Auscultate the patient’s bilateral breathing. note the absence of bowel sounds. such as a burn or crush injury. and diaphoresis). diabetic ketoacidosis. and confusion may be indicators of diminished cerebral perfusion and are among the early signs of of hypovolemic shock. and temperature. including heart and respiratory rate. blood pressure. If the patient can maintain the ABCs. Monitor vital signs. internal gastrointestinal bleeding. and signs of sympathetic nervous system stimulation (tachycardia. bleeding may be causing blood to shunt to other more vital organs. which may indicate a paralytic ileus. diarrhea. and diabetes insipidus can also cause hypovolemia. Likewise. obtain a subjective history of thirst. does initially widen and then narrow in the first two stages of shock. Other early indicators include a decreased urinary output of less than 30 mL/hr. Excessive diuresis from diuretic overuse. Changes in blood pressure (particularly hypotension) are a late rather than an early sign. assessment. If bowel sounds are hypoactive. current medications. The patient may appear either stable and alert or critically ill. Inspect the patient’s neck veins and palpate them for the quality of carotid pulse and neck vein appearance. Auscultate the patient’s heart. it is important to remember that the most obvious injury site may not be the cause of the evolving of hypovolemic shock. Elicit information from the patient. lethargy. In the case of traumatic blood loss. and note any new murmurs or other adventitious heart sounds. assess the patient’s level of consciousness. piloerection [gooseflesh]). breathing. or diuresis—is a potential indicator. The primary survey is a rapid (30 to 60 seconds) head-to-toe assessment that encompasses the emergency management of threats to airway. a history of either recent alterations in fluid volume intake or excessive loss—as in vomiting. or the family as to how much blood was lost or how long the bleeding has continued. and circulation (ABCs) or life. Explore the possibility of a mechanism of injury. and the factors that surround the hypovolemic/hemorrhagic condition. Restlessness. pulse pressure. Orthostatic blood pressure changes also indicate hypovolemia. Nursing care plan assessment and physical examination If the patient is actively bleeding or is severely compromised. Inspect the patient’s abdomen for possible sites of fluid loss or compartmenting. excessive diaphoresis. Palpate the patient’s peripheral pulses and note signs of decreased blood flow and inadequate tissue perfusion (cold. clammy skin. delayed capillary blanching. If the patient’s condition is stable enough to warrant a separate history. however. anxiety. and note the patient’s respiratory effort. leading to plasma fluid shifts extravascularly. excessive nasogastric drainage. ask questions about allergies. patients who are experiencing hypovolemia because of trauma have either obvious bleeding or a history of injury to a vascularized area. draining wounds. When you auscultate the patient’s abdomen. diarrhea. weak. preexisting medical conditions.

It is currently recommended to use caution in replacing fluids after trauma because the low flow state may protect the patient from further bleeding until the traumatic injury is repaired. controlling the source of blood loss. fluid resuscitation can be used aggressively. although O-negative can be used if type-specific blood is not immediately available. Spouses of critically injured patients deal with role reversals. If the patient has a decreased level of consciousness. Three milliliters of crystalloid solutions should be infused for every 1 mL of blood loss. life-threatening event that may lead to the death of a child. and (4) external bleeding. Nursing care plan intervention and treatment plan The initial care of the patient with of hypovolemic shock follows the ABCs of resuscitation. the patient has a lower risk of hypothermia. Although vasopressors. Expect the family and partner of critically injured patients to express a range of emotions from fear and anxiety to grief and guilt. After repair. but remember that these signs are late indicators of of hypovolemic shock and may not be present until the patient reaches stage III. attempt to identify a family member or significant other to discuss the patient’s psychosocial history. The objective of fluid replacement is to provide for adequate cardiac output to perfuse the tissues. RBCs are preferred because they contain an increased percentage of hemoglobin per volume. large-bore peripheral intravenous (IV) catheter in a large peripheral vein. do increase blood pressure in the setting of of hypovolemic shock. but only red blood cells (RBCs) can carry enough oxygen to maintain cellular function. Fluid resuscitation is most efficient through a short. (3) thighs (check for deformities and bleeding into soft tissues. Of particular concern are the parents of young trauma patients who have to deal with a sudden. fluid resuscitation occurs more rapidly. (2) abdomen (examine for tenderness or distension). If fluids can be warmed before infusion. Generally. . anxious.capillary refill). The American College of Surgeons recommends crystalloid fluids such as normal saline solution or lactated Ringer’s solution for stages I and II and crystalloids plus blood products for stages III and IV. The IV line should have a short length of tubing from the bag or bottle to the IV site. If pressure is applied to the bag. Measures to ensure adequate oxygenation and tissue perfusion include establishing an effective airway and a supplemental oxygen source. and in need of support. RBCs or whole blood should be considered when fluid resuscitation with crystalloids is not successful. and the fear of loss. Expect family members to be frightened. Type-specific blood is preferred. After initial stabilization of airway and breathing. the most important nursing intervention is to ensure timely fluid replacement. they should never be started if there is insufficient intravascular fluid or if tissues remain underperfused despite an adequate blood pressure. economic crises. Four areas are considered to be life threatening: (1) chest (auscultate for decreased breath sounds). any fluid transiently improves perfusion. such as norepinephrine or dopamine. Nursing care plan primary nursing diagnosis: Fluid volume deficit related to active bleeding or fluid loss. and replacing intravascular volume.

and answer the patient’s and family’s questions. and anemia. place the patient in a modified Trendelenburg’s position to facilitate venous return and to prevent excessive abdominal viscera shift and restriction of the diaphragm that occurs with the head-down position. If the patient is awake. provide a running explanation of the procedures to reassure him or her. Patients and their families are often frightened and anxious. As required. Explain the risks of blood transfusion. . If blood component therapy is essential. provide information about any follow-up laboratory procedures that might be needed after the patient is discharged. infection.Positioning the patient can also increase perfusion throughout the body. Nursing care plan discharge and home health care guidelines Provide a complete explanation of all emergency treatments. and answer any questions about exposure to blood-borne infections. answer the patient’s and family’s questions about the risks involved. such as poor wound healing. Hold the patient’s hand to offer reassurance when possible. Explain the possibility of complications to recovery. Explain the treatment alternatives to the family and keep them updated as to the patient’s response to therapy.