NCP IGNAS, MICHELLE

CASE: HYPOVOLEMIC SHOCK

ASSESSMEN DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

T
OBJECTIVE Inadequate After 30 mins. INDEPENDENT:  For the After 30 mins.
Bp 70/50 tissue Of fluid  Patient teaching. awareness Of fluid
PR 130 bpm perfusion replacement  Proper of the replacement
RR 38 cpm related to and treatment Positioning: patient, and treatment
decrease for blood loss, Modified prevent for blood loss.
SUBJECTIVE intravascular the Bp of the threndelenburgs anxiety The Bp of the
volume.blood patient will Position. and patient turn
loss. turn near  Close monitoring of establish near
normal, vital signs. raport. normal,palene
paleness will  Assess the  To ss is reduced
reduce and improvement of promote and the
patient will patients condition. fluid patient now
breathe  Assess the side effect redistributi breathes
normally. In of medications. on. normally. In
general, the  Assuring proper  For early general the
VS administration of detection patient’s VS is
OF THE medications. of possible improving the
PATIENT WILL  Raise bed’s side rails. complicati problem was
IMPROVE,the  Monitor fluid I&O. on. resolved and
problem will  Documentation.  To assess thus,further
be resolved INDEPENDENT: for the complication is
and thus,will  MEDICATIONS effectivene prevented.
prevent  IV INFUSIONS ss of the
further  BLOOD treatment
complications. TRANSFUSION  To
 OXYGEN promote
ADMINISTRATION safety of
the
patient.
 To assess if
the patient
respond to
the fluid
replaceme
nt.
 To know
what are
the
treatment
given and
not given
to the
patient.
Pathophysiology
Hypovolemic shock
DECREASE
INTRAVASCULAR
VOLUME

DECREASED VENOUS
RETURN TO THE HEART

DECREASED INTRA
VASCULAR FILLING

DECREASED STROKE
VOLUME (amt. of
blood ejected from
the heart)

Decrease cardiac
output

Bp drops

Inadequate tissue
perfusion