Nursing Care Plan for Hypovolemic Shock

Pathophysiology

Hypovolemic shock is a loss of blood volume leading to decreased oxygenation of vital organs. The body’s compensatory mechanisms fail and organs begin to shut down.

Etiology

Any condition causing loss of circulating blood or plasma volume. Hemorrhage from any large source. Traumatic injuries. Burns (plasma loss due to capillary permeability). Prolonged vomiting or diarrhea.

Desired Outcome

The goal is to restore circulating blood volume, preserve hemodynamics, and prevent any damage to vital organs.

Hypovolemic Shock Nursing Care Plan

Subjective Data:

  • Weakness
  • Anxiety or restlessness
  • Report of vomiting or diarrhea
  • Report of rectal or vaginal bleeding

Objective Data:

  • Measured fluid loss > 1500 mL
  • Hemorrhage or Burn
  • ↑ HR
  • ↑ RR
  • ↓ BP
  • ↓ CVP
  • ↓ CO
  • ↑ SVR
  • ↓ LOC
  • ↓ Urine output
  • Cool, pale, clammy skin

Nursing Interventions and Rationales

  • Assess for Risk
    • bleeding risk
    • burns
    • GI/GU losses

 

Causes of shock include:

  • Blood loss from:
    • Traumatic injuries
    • Internal bleeding, such as a GI bleed or surgical complication
    • Postpartum hemorrhage
  • Fluid loss from:
    • Burns
    • Diarrhea
    • Vomiting

Nurses should assess their patient for the risk of developing hypovolemic shock. The patient may have lost some fluid already, or maybe they’re at risk for bleeding. Either way, the more aware the nurse is of the risk, the more likely it can be prevented or caught early.

 

  • Assess and monitor VS and LOC

 

Patient may develop tachycardia and tachypnea in the early stages, then hypotension in later stages. It’s important to note these changes in the patient. Monitoring VS could help to prevent hypovolemic shock if caught early, but will also help to determine the patient’s response to treatment.  

Level of consciousness should be assessed because it may decrease as the patient loses oxygenation of their brain. Decreasing LOC is a sign of advancing shock.

Notify the provider for:

  • ↓ blood pressure, not responding to fluids. If the blood pressure continues to drop, the patient will lose perfusion to vital organs.
  • ↓ LOC – if the patient is more difficult to arouse or confused, this could be a sign of advancing shock. They may also begin to have difficulty protecting their own airway – the provider needs to be notified

 

  • Monitor Hemodynamics
    • MAP
    • CVP
    • CO
    • SVR

 

Hemodynamic measurements will tell us the severity of the shock and how well the patient is responding to treatment.

  • MAP = Mean Arterial Pressure – this is the average pressure within the arteries. It can be calculated with a non-invasive blood pressure, but is more accurate when measured by  an Arterial Line. Decompensated shock will show a decreasing MAP below 60 mmHg
  • CVP = Central Venous Pressure. This measures Preload. In a patient with hypovolemic shock, it will be low (<4 mmHg). The goal would be to see this number as well as the CO increase with fluid resuscitation
  • CO = Cardiac Output. As the patient’s preload decreases, so does their cardiac output. The body will attempt to compensate, so you may see a normal cardiac output for a while – then it will begin to drop as the body’s compensatory mechanisms fail. This is assessed using a FloTrac or PA catheter
  • SVR = Systemic Vascular Resistance. This measures afterload. We will expect this to be high because of the body’s attempts to compensate through vasoconstriction. If fluid resuscitation is effective, we will see this number return back down to normal

 

  • Prepare for procedures
    • Arterial Line or Central Line Placement
      • Gather all supplies
      • Ensure consent is obtained by provider
      • Explain procedure to patient/family
      • Prep fluids or tubing
      • Ensure all monitoring equipment is available
    • Intubation
      • Notify Respiratory Therapist and Charge Nurse for support
      • Suction and Ambu Bag at the bedside
      • Gather supplies
      • Ensure all monitoring equipment is available
    • OR
      • Follow facility procedures
      • Remove all personal clothes, jewelry, etc.
      • Ensure informed consent is obtained by provider
      • Facilitate transport

 

Arterial lines are placed for invasive hemodynamic monitoring. They can measure MAP, but can also measure other hemodynamic values such as CO/CI, SVR, SV, etc. when using a FloTrac machine.

Central lines are placed for administration of fluids and medications as well as hemodynamic monitoring of CVP, CO/CI, and SVR. Patients who have severe hemorrhages may receive a large bore (12g) central catheter called a Cordis so they can receive large volumes of fluids rapidly.

Patients whose airway has been compromised due to ↓ LOC may need to be intubated to protect their airway, and placed on a ventilator.

Patients may need to be taken to the OR to repair the injury or internal bleeding that caused the hypovolemia in the first place.

**Informed consent MUST be obtained by the provider. You can explain procedures to patients/family, but the provider must give the reason, risks, benefits, etc. and obtain the informed consent.

 

  • Insert 2 Large Bore IV’s
    “Short and thick does the trick”

    How fast can 1 L be infused?
    12g Cordis – 1:05 min
    16g PIV – 2:20 min
    18g PIV – 4:23 min
    14g CVC – 5:20 min
    20g PIV – 6:47 min

    PIV = Peripheral IV catheter
    CVC = Central Venous Catheter
    (Buck, 2015)

 

The patient will need large bore IV access in order to administer fluid resuscitation. This should be done with a pressure bag or rapid infuser.

The highest possible rate on an infusion pump is 999 mL/hr. At this rate, 1 L of fluids takes 1 hour to infuse. Shorter and thicker catheters will provide for faster fluid administration.

 

  • RAPID IV Bolus Fluids

 

Fluids should be given as soon and as fast as possible to restore circulating blood volume.

  • Crystalloid – to replace fluid loss from sources other than bleeding/hemorrhage
    • Normal Saline
    • Lactated Ringers
  • Colloid to replace lost blood volume from hemorrhage

 

  • Administer Blood Products
    • Obtain Consent
    • Send Type & Crossmatch
    • Monitor per protocol
    • Packed Red Blood Cells
    • Fresh Frozen Plasma
    • Massive Transfusion Protocol – used to prevent clotting problems when patients receive multiple units of blood.

 

For patients who have lost significant amounts of blood due to trauma or hemorrhage, they should receive transfusions of blood products.

Be sure that consent is obtained and that the patient is aware of possible reactions. Send a type and crossmatch to determine the patient’s blood type. Verify the blood product with another nurse prior to administering and monitor per facility protocol for transfusion reactions. Usually this is q15min x 2, q30 min x 1, and q1h after that for standard infusions. However, in hypovolemic shock, even blood products are given via rapid infusion.

Packed Red Blood Cells (PRBC’s) do not contain clotting factors, platelets, or plasma – therefore patients may have trouble clotting after receiving multiple units of PRBC’s. During massive transfusion protocol, units of plasma, platelets, and clotting factors are given at certain intervals to prevent this clotting problem.

 


References

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