Nursing Care Plan

Nursing Diagnosis Decreased cardiac output related to decreased venous return to the heart secondary to hypovolemia Objective: After 8 hours of nursing intervention, the patient will maintain BP within normal limits; warm, dry skin; regular cardiac rhythm; and strong bilateral, equal peripheral pulses.

Nursing Care Plan

INTERVENTIONS
 Assess for early warning signs of hypovolemia

RATIONALE
 Mild to moderate anxiety and tachycardia may be the first signs of impending hypovolemic shock; these may be easily overlooked or attributed to pain, psychological trauma, and fear. BP is not a good indicator of early hypovolemic shock

Nursing Care Plan

INTERVENTIONS
 Assess HR, BP, and pulse pressure. Use direct intraarterial monitoring as ordered

RATIONALE
 Sinus tachycardia and increased arterial BP are seen in erarly stages to maintain an adequate cardiac output; BP drops as condition deteriorates. In young adults, compensatory mechanism responses maintain a normal BP until major blood loss occurs

Nursing Care Plan

INTERVENTIONS
 Record and evaluate I&O

RATIONALE
 Accurate measurement is essential in detecting fluid volume loss.  Primary survey helps identify imminent or potentially life-threatening injuries. This is a quick initial assessment

 If trauma has occured, evaluate and document extent of patient's injuries; use primary survey or ABCs

Nursing Care Plan

INTERVENTIONS
 Obtain spun hematocrit, and reevaluate every 30 minutes to 4 hours, depending on stablity

RATIONALE
 Hematocrit decreases as fluids are administered because of dilution. As a rule of thumb, hematocrit decreases 1% per liter of LRS or NSS used. Any other hematocrit decrease must be evaluated as an indication of continued blood loss

Nursing Care Plan

INTERVENTIONS
 For trauma victims with internal bleeding, military antishock trousers (MAST) or pneumatic antishock garment (PASG) may be used  Assess skin color, temperature, and moisture

RATIONALE
 These devices are useful to

tamponade bleeding, these trousers may be used to reduce tissue and vessel damage

 Cool, pale, clammy skin is

secondary to compensatory increase in sympathetic nervous system stimulation and low cardiac output and desaturation

Nursing Care Plan

INTERVENTIONS
 Assess for mental status changes

RATIONALE
 Early signs of cerebral hypoxia

are restlessness and anxiety, with confusion and loss of consciousness occuring in later stages.

 Assess urine output with a foley catheter

 The renal system

compensates for low BP by retaining water. Oliguria is a classic sign of inadequate renal perfusion form reduced cardiac output

Nursing Care Plan

INTERVENTIONS
 Assess heart sounds, noting gallops, S3, S4.

RATIONALE
 S3 denotes reduced left

ventricular ejection and is a classic sign of left ventricular failure. S4 occurs with reduced compliance of the left ventricle, which impairs diastolic filling.
drainage from the legs and increases circulating blood volume as much as 800 ml, this measure will exacerbate the conditions indicated

 Elevate the patient's leg above heart level, unless contraindicated by active bleeding from the head and neck

 Elevation promotes venous

Nursing Care Plan

INTERVENTIONS
 Administer crystalloids such as PLRS. Use the three-to-one rule. For every 1 ml of of blood loss, 3 ml of crystalloid should be given.  Monitor the client s temperature at least every hour.

RATIONALE
 Fluid replacement is to provide

for adequate cardiac output to perfuse the tissues.

Patients receiving large volumes of fluid are at risk of hypothermia. Hypothermia is a cardiac depressant and can predispose the client to cardiac arrhythmias. It can also alter clotting mechanisms and place the patient at risk for coagulopathic consequences.

Nursing Care Plan

INTERVENTIONS
 Have the patient use

RATIONALE
 To prevent hypothermia and

warming blankets or heat lamps.

shivering. It is important to remember that shivering increases metabolic demands for oxygen up to 400%. This additional demand for oxygen is crucial in the patient who is suffering from tissue hypoxia.


 Place in supine position. Do

not attempt to place the patient in Trendelenburg position.

This increases venous return, promotes diuresis.

Nursing Care Plan

INTERVENTIONS
 * Administer stool softeners as needed.

RATIONALE
 To prevent hypothermia and Straining for a bowel movement further impairs cardiac output.  This increases venous return, promotes diuresis.

 Monitor sleep patterns.