4 Hypovolemic Shock Nursing Care Plans

Decreased Cardiac Output

Nursing Diagnosis

• 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.
• Tachycardia.

Desired Outcomes

• 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.