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.
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.
- 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.
|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.|
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
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:
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- Anemia | 4 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