Hypovolemic Shock also known as a hemorrhagic shock is a medical condition resulting from a decreased blood volume caused by blood loss, which leads to reduced cardiac output and inadequate tissue perfusion. Common causes include internal or external bleeding, extensive burns, vomiting, profuse sweating, and diarrhea. Hypovolemic Shock also often occurs after trauma, GI bleeding, or rupture of organs or aneurysms. The symptoms are dependent on the severity of fluid or blood loss. However, all symptoms of shock are life-threatening and must be given medical treatment immediately. The prognosis is dependent on the degree of volume loss.
Nursing Care Plans
Nursing care for patients with Hypovolemic Shock focuses on assisting with treatment aimed at the cause of the shock and restoring intravascular volume.
Here are four (4) nursing care plans and nursing diagnoses for a hypovolemic shock:
Decreased Cardiac Output
May be related to
- Alterations in heart rate and rhythm.
- Decreased ventricular filling (preload).
- Fluid volume loss of 30% or more.
- Late uncompensated hypovolemic shock.
Possibly evidenced by
- Abnormal arterial blood gasses (ABGs); hypoxemia and acidosis.
- Capillary refill greater than 3 seconds.
- Cardiac dysrhythmias.
- Change in level of consciousness.
- Cold, clammy skin.
- Decreased urinary output (less than 30 ml per hour).
- Decreased peripheral pulses.
- Decreased pulse pressure.
- Decreased blood pressure.
- The client will maintain adequate cardiac output, as evidenced by strong peripheral pulses, systolic BP within 20 mm Hg of baseline, HR 60 to 100 beats per minute with a regular rhythm, urinary output of 30 ml/hr or greater, warm and dry skin, and normal level of consciousness.
Nursing Assessment and Rationales
1. Assess the client’s HR and BP, including peripheral pulses. Use direct intra-arterial monitoring as ordered.
Sinus tachycardia and increased arterial BP are seen in the early stages to maintain an adequate cardiac output. Hypotension happens as the condition deteriorates. Vasoconstriction may lead to unreliable blood pressure. Pulse pressure (systolic minus diastolic) decreases in shock. Older clients have reduced response to catecholamines; thus their response to decreased cardiac output may be blunted, with less increase in HR.
2. Assess the client’s ECG for dysrhythmias.
Cardiac dysrhythmias may occur from the low perfusion state, acidosis, or hypoxia, as well as from side effects of cardiac medications used to treat this condition.
3. Assess the central and peripheral pulses.
Pulses are weak, with reduced stroke volume and cardiac output.
4. Assess capillary refill time.
Capillary refill is slow and sometimes absent.
5. Assess the respiratory rate, rhythm, and auscultate breath sounds.
Characteristics of a shock include rapid, shallow respirations and adventitious breath sounds such as crackles and wheezes.
6. Monitor oxygen saturation and arterial blood gases.
Pulse oximetry is used in measuring oxygen saturation. The normal oxygen saturation should be maintained at 90% or higher. As shock progresses, aerobic metabolism stops and lactic acidosis occurs, resulting in an increased level of carbon dioxide and decreasing pH.
7. Monitor the client’s central venous pressure (CVP), pulmonary artery diastolic pressure (PADP), pulmonary capillary wedge pressure, and cardiac output/cardiac index.
CVP provides information on filling pressures of the right side of the heart; pulmonary artery diastolic pressure and pulmonary capillary wedge pressure reflect left-sided fluid volumes. Cardiac output provides an objective number to guide therapy.
8. Assess for any changes in the level of consciousness.
Restlessness and anxiety are early signs of cerebral hypoxia while confusion and loss of consciousness occur in the later stages. Older clients are especially susceptible to reduced perfusion to vital organs.
9. Assess urine output.
The renal system compensates for low BP by retaining water. Oliguria is a classic sign of inadequate renal perfusion from the reduced cardiac output.
10. Assess skin color, temperature, and moisture.
Cool, pale, clammy skin is secondary to a compensatory increase in sympathetic nervous system stimulation and low cardiac output and desaturation.
Nursing Interventions and Rationales
1. Provide electrolyte replacement as prescribed.
Electrolyte imbalance may cause dysrhythmias or other pathological states.
2. If possible, use a fluid warmer or rapid fluid infuser.
Fluid warmers keep core temperature. Infusing cold blood is associated with myocardial dysrhythmias and paradoxical hypotension. Macropore filtering IV devices should also be used to remove small clothes and debris.
3. Administer fluid and blood replacement therapy as prescribed.
Maintaining an adequate circulating blood volume is a priority.
4. If the client’s condition progressively deteriorates, initiate cardiopulmonary resuscitation or other lifesaving measures according to Advanced Cardiac Life Support guidelines, as indicated.
Shock unresponsive to fluid replacement can worsen into cardiogenic shock. Depending on etiological factors, vasopressors, inotropic agents, antidysrhythmics, or other medications can be used.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues and on electrolytes and acid-base balance.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
The definitive guide to nursing diagnoses is reviewed and approved by the NANDA International. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis…. subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans for hematologic and lymphatic system disorders:
- Anaphylactic Shock | 4 Care Plans
- Anemia | 5 Care Plans
- Aortic Aneurysm | 4 Care Plans
- Deep Vein Thrombosis | 5 Care Plans
- Disseminated Intravascular Coagulation | 4 Care Plans
- Hemophilia | 5 Care Plans
- Leukemia | 5 Care Plans
- Lymphoma | 3 Care Plans
- Sepsis and Septicemia | 6 Care Plans
- Sickle Cell Anemia Crisis | 6 Care Plans