Nursing Care Plan (NCP) for Hypovolemic Shock

Lesson Objective for Hypovolemic Shock

• Understanding of Hypovolemic Shock:
  • Gain knowledge about the pathophysiology, causes, and risk factors of hypovolemic shock. Understand how a decrease in circulating blood volume leads to inadequate tissue perfusion.
• Recognition of Signs and Symptoms:
  • Develop the ability to recognize the clinical manifestations of hypovolemic shock, including but not limited to tachycardia, hypotension, rapid breathing, cool and clammy skin, and altered mental status. This involves understanding the physiological response to decreased blood volume.
• Identification of Underlying Causes:
  • Learn to identify and assess the underlying causes of hypovolemic shock, such as hemorrhage, severe dehydration, or fluid loss from trauma. Recognize the importance of a thorough patient history and physical examination in determining the cause.
• Emergency Interventions:
  • Acquire skills in implementing emergency interventions to address hypovolemic shock. This includes initiating fluid resuscitation, administering blood products when necessary, and ensuring prompt and appropriate medical interventions to stabilize the patient’s condition.
• Monitoring and Evaluation:
  • Develop proficiency in continuous monitoring of vital signs, urine output, central venous pressure, and laboratory values. Understand the importance of ongoing assessment to evaluate the effectiveness of interventions and make timely adjustments to the care plan.

Pathophysiology of Hypovolemic Shock

 

• Inadequate Circulating Blood Volume:
  • Hypovolemic shock results from a significant decrease in the volume of circulating blood in the body. This can occur due to various factors, such as hemorrhage, severe dehydration, or fluid loss from burns.
• Decreased Preload and Stroke Volume:
  • The reduction in blood volume leads to decreased preload, the amount of blood returning to the heart. As a consequence, stroke volume—the amount of blood ejected with each heartbeat—also decreases, compromising the cardiac output.
• Compensatory Mechanisms:
  • The body activates compensatory mechanisms to maintain perfusion to vital organs. These mechanisms include increased heart rate (tachycardia) to enhance cardiac output and peripheral vasoconstriction to redirect blood flow to essential organs.
• Tissue Hypoperfusion:
  • Despite compensatory efforts, the reduced blood volume results in inadequate perfusion of tissues and organs. This can lead to cellular hypoxia, affecting cellular metabolism and function.
• Activation of the Renin-Angiotensin-Aldosterone System (RAAS):
  • The decrease in blood volume triggers the activation of the RAAS, leading to the release of renin, angiotensin II, and aldosterone. These hormones aim to retain water and sodium, increase blood pressure, and stimulate vasoconstriction to restore blood volume.

Etiology of Hypovolemic Shock

• Hemorrhage:
  • Severe bleeding, whether from trauma, surgery, or gastrointestinal bleeding, is a common cause of hypovolemic shock. Rapid loss of blood reduces the circulating volume, triggering shock.
• Dehydration:
  • Inadequate fluid intake, excessive fluid loss through vomiting, diarrhea, or excessive sweating, and conditions like diabetes insipidus can lead to dehydration. Dehydration results in a decrease in blood volume, contributing to hypovolemic shock.
• Burns:
  • Extensive burns, especially those involving a large surface area, can result in significant fluid loss due to increased permeability of damaged blood vessels. This fluid

Desired Outcome of Nursing Care for Hypovolemic Shock

• Restoration of Circulatory Volume:
  • The primary goal is to restore and maintain an adequate circulating blood volume to ensure adequate perfusion to vital organs and tissues.
• Hemodynamic Stability:
  • Achieve and maintain stable blood pressure, heart rate, and oxygen saturation within normal ranges to support organ perfusion.
• Resolution of Causative Factors:
  • Identify and address the underlying cause of hypovolemic shock, such as controlling bleeding, rehydrating the patient, or addressing other contributing factors.
• Prevention of Complications:
  • Minimize and prevent complications associated with hypovolemic shock, such as organ failure, coagulopathy, and electrolyte imbalances.
• Patient Education:
  • Provide education to the patient and their caregivers on measures to prevent future occurrences, recognizing early signs of shock, and the importance of seeking prompt medical attention.

Hypovolemic Shock Nursing Care Plan

 

Nursing Assessment for Hypovolemic Shock

• Vital Signs:
  • Monitor blood pressure, heart rate, respiratory rate, and temperature frequently to assess the patient’s hemodynamic status.
• Skin Assessment:
  • Evaluate skin color, temperature, and moisture for signs of poor perfusion, such as pallor, coolness, and clamminess.
• Capillary Refill:
  • Assess capillary refill time, which can provide information about peripheral perfusion and circulatory status.
• Mental Status:
  • Monitor the patient’s level of consciousness, orientation, and responsiveness to assess neurological perfusion.
• Urine Output:
  • Measure urine output to evaluate renal perfusion and function, as decreased urine output may indicate inadequate organ perfusion.
• Respiratory Assessment:
  • Monitor respiratory effort, auscultate lung sounds, and assess for signs of respiratory distress to evaluate oxygenation and ventilation.
• Fluid Balance:
  • Assess fluid balance by monitoring input and output, including intravenous fluids, oral intake, and urine output.
• Laboratory Values:
  • Obtain and monitor laboratory values such as hemoglobin, hematocrit, electrolytes, and coagulation studies to identify abnormalities and guide treatment.

Implementation for Hypovolemic Shock

• Fluid Resuscitation:
  • Initiate rapid intravenous (IV) fluid administration with crystalloids (e.g., normal saline) to restore circulating volume and improve tissue perfusion.
• Blood Transfusion:
  • Administer blood products (packed red blood cells) if significant blood loss has occurred to improve oxygen-carrying capacity.
• Vasoactive Medications:
  • Consider the use of vasoactive medications (e.g., dopamine, norepinephrine) to support blood pressure and cardiac output in severe cases.
• Positioning:
  • Elevate the lower extremities to promote venous return and reduce pooling of blood in the extremities.
• Monitoring:
  • Continuously monitor vital signs, urine output, and laboratory values to assess the response to interventions and adjust the treatment plan accordingly.

Nursing Interventions and Rationales

 

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

• Assess and monitor VS and LOC

• Monitor Hemodynamics
  • MAP
  • CVP
  • CO
  • SVR

• Prepare for procedures
  • Arterial Line or Central Line Placement
    • Gather all supplies
    • Ensure consent is obtained by the 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 the provider
    • Facilitate transport

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

• RAPID IV Bolus Fluids

• 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.

Evaluation for Hypovolemic Shock

 

• Hemodynamic Stability:
  • Assess for stabilization of hemodynamic parameters, including blood pressure, heart rate, and central venous pressure.
• Urine Output:
  • Monitor urine output to ensure adequate renal perfusion and function. Improved urine output is indicative of better tissue perfusion.
• Laboratory Values:
  • Evaluate laboratory values such as hemoglobin and hematocrit to assess for improvements in oxygen-carrying capacity and blood volume.
• Clinical Signs:
  • Observe for resolution of clinical signs and symptoms of shock, including improved mentation, skin perfusion, and capillary refill time.
• Response to Interventions:
  • Assess the patient’s response to implemented interventions, making adjustments as needed based on ongoing monitoring and evaluation of the patient’s condition.

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References

• http://etmcourse.com/large-bore-iv-access-showdown/
• https://emedicine.medscape.com/article/760145-overview
• https://medlineplus.gov/ency/article/000167.htm