Nursing Care Plan (NCP) for Hypovolemic Shock

Join NURSING.com to watch the full lesson now.

Included In This Lesson

Outline

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 patients 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

  Patients 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.   The level of consciousness should be assessed because it may decrease as the patient loses the 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 the 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 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
  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 minPIV = 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 the massive transfusion protocol, units of plasma, platelets, and clotting factors are given at certain intervals to prevent this clotting problem.

Writing a Nursing Care Plan (NCP) for Hypovolemic Shock

A Nursing Care Plan (NCP) for Hypovolemic Shock starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

Join NURSING.com to watch the full lesson now.

Transcript

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!

 

Join NURSING.com to watch the full lesson now.