Nursing Care Plan (NCP) for Hypovolemic Shock

Watch More! Unlock the full videos with a FREE trial

Add to Study plan

Included In This Lesson

Access More! View the full outline and transcript with a FREE trial


Today, we're going to be talking about hypovolemic shock in its associated care plan. In this lesson, we will briefly take a look at the pathophysiology and etiology of hypovolemic shock. We're also going to look at additional things like subjective and objective data that your patient may present with as well as nursing interventions and rationales. 


Hypovolemic shock is the loss of blood volume, which leads to decreased oxygenation of vital organs. This loss of blood volume results in the body's compensatory mechanisms failing and organs therefore shutting down. Hypovolemic shock can be caused by any condition that causes a loss of circulating blood volume or plasma volume, which includes things like hemorrhage, traumatic injuries, burns, and even prolonged vomiting or diarrhea. The desired outcome is to restore circulating blood volume, preserve hemodynamics, and prevent any damage to those vital organs. 


So let's take a look at some of the subjective and objective data that your patient with hypovolemic shock may present with now, remember subjective data are going to be the things that are based on your patient's opinions or feelings. So, for hypovolemic shock, this could include weakness, anxiety, or restlessness, report of vomiting, diarrhea, rectal, or even vaginal bleeding. 


Objective data might include a measured fluid loss that's greater than 1500 milliliters, hemorrhage or burn, increased heart rate, respiratory rate, systemic vascular resistance, and also decreased blood pressure, CVP, level of consciousness, urine output, and cool/ clammy skin. 


Let's start to take a look at some of the specific nursing interventions for hypovolemic shock. It is definitely important to assess the risk of bleeding, burns, and GI and GU losses. This is because hypovolemic shock can be caused by blood loss from traumatic injuries, internal bleeding, like a GI bleed or a surgical complication, and postpartum hemorrhage or fluid loss from burns, diarrhea and vomiting. So, it is important for the nurse to identify these risks so they can be caught early. Assessing and monitoring vital signs as well as level of consciousness are critical because they can signify advancing shock. In the early stages of shock, the patient may be tachycardic or tachypneic, and then it advances to hypotension, so, decreased BP in the later stage. Monitoring vital signs could help to prevent hypovolemic shock if caught early, but also help to determine the patient's response to treatment. So, level of consciousness should be assessed because it may decrease as the patient loses oxygenation to the brain. Decreasing LOC is a sign of advancing shock. Notify the provider if low blood pressure is not responding to fluids or if the patient is becoming harder to arouse. Monitoring hemodynamics is important to identify the severity of the shock and how well the patient is responding to treatment. 


Measurements should include main arterial pressure or MAP, which is the average pressure within the arteries. A MAP that is decreasing below 60 millimeters of mercury shows de-compensating shock. Central venous pressure measures the preload, which will be less than four millimeters of mercury in a patient with hypovolemic shock. The goal is to see this number, as well as the cardiac output increase with treatment. Speaking of cardiac output, this value may be normal for a while until the body's compensatory mechanisms begin to fail. Cardiac output value is assessed with a flow track or a PA catheter. So guys, systemic vascular resistance or SVR measures the afterload. We expect this to be high because of vasoconstriction, which is a compensatory mechanism. If fluid resuscitation is effective, we will see this value return to normal. With Hypoglycemic shock, we may need to prepare the patient for certain procedures like in arterial line or central line placement for invasive hemodynamic monitoring. Even for intubation, if there's a decrease in consciousness in order to protect the patient's airway, or a trip to the OR to repair internal bleeding. So, for line placement or preparation, be sure you have consent, be short as obtained by the provider and explain the procedure to the patient and family, and follow facility procedures. Also, be sure to gather any necessary supplies and prep lines and tubing, if necessary and remove patient belongings like clothes and jewelry, if they're going to the OR. So, with hypovolemic shock, replacing fluids is super critical.


How do we do this? First, we insert two large bore IV’s. Here's a way to remember this: “short and thick does the trick.” Shortening the catheters will provide your faster fluid administration, which is done with a pressure bag and rapid infuser. An infusion pump is only capable of infusing one liter an hour, so fluids should be given as soon as possible and as fast as possible to restore circulating blood volume. Crystalloids like normal saline and lactated ringers are used to replace fluid loss from sources other than bleeding or hemorrhage. Colloids are used to replace lost volume from hemorrhage with the administration of blood products like packed red blood cells and fresh frozen plasma for hemorrhage or trauma. 


There are definitely things that we as nurses must know. First of all, consent must be obtained for blood administration. With the patient understanding possible reactions, send a type and crossmatch to determine the patient's blood type. Before administration, the blood must be checked with another RN monitor using your facilities protocol. Usually, this would be every 15 minutes, times two, every 30 minutes times one in every hour after that. However, in hypovolemic shock, even blood products are given rapidly. 


Here is a look at the completed hypovolemic shock care plan. Let's do a quick review. Hypovolemic shock is the loss of blood volume leading to decreased oxygenation of organs. Causes include hemorrhage, traumatic injuries, burns, vomiting, and diarrhea. Subjective data includes weakness, anxiety, reports of vomiting, diarrhea, vaginal rectal bleeding. Objective data includes fluid volume loss of greater than 1500 mls, increased heart rate, respiratory rate, systemic vascular resistance, decrease BP, CVP, cardiac output level of consciousness, urine output, and cool pale clammy skin. Assess and monitor vital signs, level of consciousness, mean arterial pressure, cardiac output, SVR, and CVP to prevent worsening shock. To evaluate treatment effectiveness, prepare the patient for arterial and central line placement for intubation for the OR, and administer crystalloids, co-leads, and blood products with a large bore IV. Remember, short and thick does the trick. 


Okay guys, that is it on this care plan lesson. We love you guys. Now, go out and be your best self today and as always, happy nursing!

View the FULL Transcript

When you start a FREE trial you gain access to the full outline as well as:

  • SIMCLEX (NCLEX Simulator)
  • 6,500+ Practice NCLEX Questions
  • 2,000+ HD Videos
  • 300+ Nursing Cheatsheets

“Would suggest to all nursing students . . . Guaranteed to ease the stress!”