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4 Hypovolemic Shock Nursing Care Plans

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By Paul Martin, BSN, R.N.
Hypovolemic Shock Nursing Care Plans
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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 diagnosis for hypovolemic shock: 

  1. Decreased Cardiac Output
  2. Deficient Fluid Volume
  3. Ineffective Tissue Perfusion
  4. Anxiety

2. Deficient Fluid Volume

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Deficient Fluid Volume

Nursing Diagnosis

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.
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2. Deficient Fluid Volume

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See also

Other recommended site resources for this nursing care plan:

Other care plans for hematologic and lymphatic system disorders:

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Paul Martin, BSN, R.N.
Paul Martin is a registered nurse with a bachelor of science in nursing since 2007. Having worked as a medical-surgical nurse for five years, he handled different kinds of patients and learned how to provide individualized care to them. Now, his experiences working in the hospital is carried over to his writings to help aspiring students achieve their goals. He is currently working as a nursing instructor and have a particular interest in nursing management, emergency care, critical care, infection control, and public health. As a writer at Nurseslabs, his goal is to impart his clinical knowledge and skills to students and nurses helping them become the best version of themselves and ultimately make an impact in uplifting the nursing profession.
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