4 Hypovolemic Shock Nursing Care Plans

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Hypovolemic Shock Nursing Care Plans

Hypovolemic Shock also known as 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 is 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 nursing care plans and nursing diagnoses for hypovolemic shock: 

Decreased Cardiac Output

Decreased Cardiac Output: Inadequate blood pumped by the heart to meet metabolic demands of the body.

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.
  • Tachycardia.

Desired Outcomes

  • 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 regular rhythm, urinary output 30 ml/hr or greater, warm and dry skin, and normal level of consciousness.
Nursing InterventionsRationale
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 condition deteriorates. Vasoconstriction may lead to unreliable blood pressure. Pulse pressure (systolic minus diastolic) decreases in shock. Older client have reduced response to catecholamines; thus their response to decreased cardiac output may be blunted, with less increase in HR.
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.
Assess the central and peripheral pulses.Pulses are weak, with reduced stroke volume and cardiac output.
Assess capillary refill time.Capillary refill is slow and sometimes absent.
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.
Monitor oxygen saturation and arterial blood gasses.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 the increased level of carbon dioxide and decreasing pH.
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.
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.
Assess urine output.The renal system compensates for low BP by retaining water. Oliguria is a classic sign of inadequate renal perfusion from reduced cardiac output.
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.
Provide electrolyte replacement as prescribed.Electrolyte imbalance may cause dysrhythmias or other pathological states.
Administer fluid and blood replacement therapy as prescribed.Maintaining an adequate circulating blood volume is a priority.
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.
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 to cardiogenic shock. Depending on etiological factors, vasopressors, inotropic agents, antidysrhythmics, or other medications can be used.

Deficient Fluid Volume

Deficient Fluid Volume: Decreased intravascular, interstitial, and intracellular fluid.

May be related to

  • Active fluid volume loss (abnormal bleeding, diarrhea, diuresis or abnormal drainage).
  • Internal fluid shifts.
  • Inadequate fluid intake and/or severe dehydration.
  • Regulatory mechanism failure.
  • Trauma.

Possibly evidenced by

  • Capillary refill greater than 3 seconds.
  • Changes in the level of consciousness.
  • Cool, clammy skin.
  • Decreased skin turgor.
  • Dizziness.
  • Dry mucous membranes.
  • Increased thirst.
  • Narrowing of pulse pressure.
  • Orthostatic hypotension.
  • Tachycardia.
  • Urine output may be normal (>30ml/hr) or as low as 20 ml/hr.

Desired Outcomes

  • Client will be normovolemic as evidenced by HR 60 to 100 beats per minute, systolic BP greater than or equal to 90 mm Hg, absence of orthostasis, urinary output greater than 30ml/hr, and normal skin turgor.
Nursing InterventionsRationale
Monitor BP for orthostatic changes (changes seen when changing from a supine to a standing position).A common manifestation of fluid loss is postural hypotension. The incidence increase with age. Note the following orthostatic hypotension significances:

  • Greater than 10 mm Hg: circulating blood volume decreases by 20%.
  • Greater than 20 to 30 mm Hg drop: circulating blood volume is decreased by 40%.
Assess the client’s HR, BP, and pulse pressure. 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 condition deteriorates. Vasoconstriction may lead to unreliable blood pressure. Pulse pressure (systolic minus diastolic) decreases in shock. Older client have reduced response to catecholamines; thus their response to decreased cardiac output may be blunted, with less increase in HR.
Assess for changes in the level of consciousness.Confusion, restlessness, headache, and a change in the level of consciousness may indicate an impending hypovolemic shock.
Monitor for possible sources of fluid loss.Sources of fluid loss may include diarrhea, vomiting, wound drainage, severe blood loss, profuse diaphoresis, high fever, polyuria, burns, and trauma.
Assess the client’s skin turgor and mucous membranes for signs of dehydration.Decreased skin turgor is a late sign of dehydration. It occurs because of loss of interstitial fluid.
Monitor the client’s intake and output.Accurate measurement is important in detecting negative fluid balance and guide therapy. Concentrated urine denotes a fluid deficit.
If trauma has occurred, evaluate and document the extent of the client’s injuries; use a primary survey (or another consistent survey method) or ABCs: airway with cervical spine control, breathing, and circulation.A primary survey helps identify potentially life-threatening injuries. This serves as a quick primary assessment.
Perform a secondary survey after all life-threatening injuries are ruled out or treated.A secondary survey uses a methodical head-to-toe inspection.
If the only visible injury is an obvious head injury, look for other causes of hypovolemia (e.g, long-bone fractures, internal bleeding, external bleeding).Hypovolemic shock following trauma usually results from hemorrhage.
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.
For postsurgical client, monitor blood loss (mark skin area, weigh dressing to determine fluid loss, monitor chest tube drainage).It is important to observe an expanding hematoma or swelling or increased drainage to identify bleeding or coagulopathy.
Monitor coagulation studies, including INR, prothrombin time, partial thromboplastin time, fibrinogen, fibrin split products, and platelet count as ordered.Specific deficiencies guide treatment therapy.
Obtain a spun hematocrit, and reevaluate every 30 minutes to 4 hours, depending on the client’s ability.Hematocrit decreased as fluids are administered because of dilution. As a rule of thumb, hematocrit decreases 1% per liter of normal saline solution or lactated Ringer’s used. Any other hematocrit decrease must be evaluated as an indication of continued blood loss.
If hypovolemia is a result of severe diarrhea or vomiting, administer antidiarrheal or antiemetic medications as prescribed, in addition to IV fluids.Treatment is guided by the cause of the problem.
Encourage oral fluid intake if able.The oral route supports in maintaining fluid balance.
If hypovolemia is a result of severe burns, calculate the fluid replacement according to the extent of the burn and the client’s body weight.Formulas such as the Parkland formula, which follows, guide fluid replacement therapy:

  • % BSA (body surface area) burned x weight in kg x 4 ml lactated Ringer’s = Total fluid to be infused over 24 hours: half given intravenously over 8 hours and half given over next 16 hours.
Prepare to administer a bolus of 1 to 2 L of IV fluids as ordered. Use crystalloid solutions for adequate fluid and electrolyte balance.The client’s response to treatment relies on the extent of the blood loss.  If blood loss is mild (15%), the expected response is a rapid return to normal BP. If the IV fluids are slowed, the client remains normotensive. If the client has lost 20% to 40% of circulating blood volume or has continued uncontrolled bleeding, a fluid bolus may produce normotension, but if fluids are slowed after the bolus, BP will deteriorate. Extreme caution is indicated in fluid replacement in older clients. Aggressive therapy may precipitate left ventricular dysfunction and pulmonary edema.
Initiate IV therapy. Start two shorter, large-bore peripheral IV lines.Maintaining an adequate circulating blood volume is a priority. The amount of fluid infused is usually more important than the type of fluid (crystalloid, colloid, blood). The amount of volume that can be infused is inversely affected by the length of the IV catheter; it is best to use large-bore catheters.
Control the external source of bleeding by applying direct pressure to the bleeding site.External bleeding is controlled with firm, direct pressure on the bleeding site, using a thick dry dressing material. Prompt, effective treatment is needed to preserve vital organ function and life.
If bleeding is secondary to surgery, anticipate or prepare for a return to surgery.Surgery may be the only option to fix the problem.
Administer blood products (e.g., packed red blood cells, fresh frozen plasma, platelets) as prescribed. Transfuse the client with whole blood-packed red blood cells.Preparing fully crossmatched blood may take up to 1 hour in some laboratories. Consider using uncrossmatched or type-specific blood until crossmatched blood is available. If type-specific blood is not available, type O blood may be used for exsanguinating clients. If available, Rh-negative blood is preferred, especially for women of child-bearing age. Autotransfusion may be used when there is massive bleeding in the thoracic cavity.
For trauma victims with internal bleeding (e.g., pelvic fracture), military antishock trousers (MAST) or pneumatic antishock garments (PASGs) may be used.These devices are useful to tamponade bleeding. Hypovolemia from long-bone fractures (e.g., femur or pelvic fractures) may be uncontrolled by splinting with air splints. Hare traction splints or MAST and/or PASG trousers may be used to redice tissue and vessel damage from the manipulation of unstable fractures.

Ineffective Tissue Perfusion

Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level.

May be related to

  • Decreased stroke volume.
  • Decreased preload.
  • Diminished venous return.
  • Severe blood loss.

Possibly evidenced by

  • Altered mental status.
  • Cool, clammy skin, pale color.
  • Cyanosis.
  • Delayed capillary refill.
  • Dizziness.
  • Shallow respirations.
  • Weak, thready pulse.

Desired Outcomes

  • Client will maintain maximum tissue perfusion to vital organs, as evidenced by warm and dry skin, present and strong peripheral pulses, vitals within patient’s normal range, balanced I&O, absence edema, normal ABGs, alert LOC, and absence of chest pain.
Nursing InterventionsRationale
Assess for signs of decreased tissue perfusion.Particular clusters of signs and symptoms occur with differing causes. Evaluation provides a baseline for future comparison.
Assess for rapid changes or continued shifts in mental status. Restlessness and anxiety are early signs of cerebral hypoxia while confusion and loss of consciousness occur in the later stages.
 Assess capillary refill.Capillary refill is slow and sometimes absent.
Observe for pallor, cyanosis, mottling, cool or clammy skin. Assess quality of every pulse.Nonexistence of peripheral pulses must be reported or managed immediately. Systemic vasoconstriction resulting from reduced cardiac output may be manifested by diminished skin perfusion and loss of pulses. Therefore, assessment is required for constant comparisons
Record BP readings for orthostatic changes (drop of 20 mm Hg systolic BP or 10 mm Hg diastolic BP with position changes).Stable BP is needed to keep sufficient tissue perfusion. Medication effects such as altered autonomic control, decompensated heart failure, reduced fluid volume, and vasodilation are among many factors potentially jeopardizing optimal BP.
Use pulse oximetry to monitor oxygen saturation and pulse rate.Pulse oximetry is a useful tool to detect changes in oxygenen saturation.
Review laboratory data (ABGs, BUN, creatinine, electrolytes, international normalized ratio, and prothrombin time or partial thromboplastin time) if anticoagulants are utilized for treatment.Blood clotting studies are being used to conclude or make sure that clotting factors stay within therapeutic levels. Gauges of organ perfusion or function. Irregularities in coagulation may occur as an effect of therapeutic measures.
Assist with position changes.Gently repositioning patient from a supine to sitting/standing position can reduce the risk for orthostatic BP changes. Older patients are more susceptible to such drops of pressure with position changes.
Provide oxygen therapy if indicated. Oxygen is administered to increase the amount of oxygen carried by available hemoglobin in the blood.
Administer IV fluids as ordered.Sufficient fluid intake maintains adequate filling pressures and optimizes cardiac output needed for tissue perfusion.

Anxiety

Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.

May be related to

  • Change in health status.
  • Fear of death.
  • Unfamiliar environment.

Possibly evidenced by

  • Agitation.
  • Apprehensive.
  • Difficulty in concentrating.
  • Increased awareness.
  • Increased questioning.
  • Sympathetic stimulation.
  • Verbalized anxiety.

Desired Outcomes

  • Client will describe a reduction in level of anxiety experienced.
  • Client will use effective coping mechanisms.
Nursing InterventionsRationale
Assess previous coping mechanism used.Anxiety and ways of decreasing perceived anxiety are highly individualized. Interventions are most effective when they are consistent with the client’s established coping pattern. However, in the acute care setting these techniques may no longer be feasible.
Assess the client’s level of anxiety.Shock can result in an acute life-threatening situation that will produce high levels of anxiety in the client as well as in significant others.
Acknowledge an awareness of the client’s anxiety.Acknowledgement of the client’s feelings validates the client’s feelings and communicates acceptance of those feelings.
Encourage the client to verbalized his or her feelings.Talking about anxiety-producing situations and anxious feelings can help the client perceive the situation in a less threatening manner.
Reduce unnecessary external stimuli by maintaining a quite environment. If medical equipment is a source of anxiety, consider providing sedation to the client.Anxiety may escalate with excessive conversation, noise, and equipment around the client.
Explain all procedures as appropriate, keeping explanations basic.Information helps reduce anxiety. Anxious clients unable to understand anything more than simple, clear, brief instructions.
Maintain a confident, assured manner while interacting with the client. Assure the client and significant others of close, continuous monitoring that will ensure prompt intervention.The staff’s anxiety may be easily perceived by the client. The client’s feeling of stability increases in a calm and non-threatening atmosphere. The presence of a trusted person may help the client feel less threatened.

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