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Polish up on client care

Beginning a smoking cessation program, if


appropriate
Reducing alcohol intake to moderate levels
Following a low-cholesterol, low-sodium
diet
Following a program of regular exercise
Losing weight, if appropriate
Contacting the American Heart
Association

Hypovolemic shock
In hypovolemic shock, reduced intravascular
blood volume causes circulatory dysfunction
and inadequate tissue perfusion. Without
sufficient blood or fluid replacement, hypovolemic shock syndrome may lead to irreversible cerebral and renal damage, cardiac arrest
and, ultimately, death.
Hypovolemic shock requires early recognition of signs and symptoms and prompt,
aggressive treatment to improve the prognosis.

CAUSES
Acute blood loss (approximately one-fifth
of total volume)
Acute pancreatitis
Dehydration from excessive perspiration
Diabetes insipidus
Diuresis
Inadequate fluid intake
Intestinal obstruction
Peritonitis
Severe diarrhea or protracted vomiting

ASSESSMENT FINDINGS
Cold, pale, clammy skin
Decreased sensorium
Hypotension with narrowing pulse
pressure
Rapid, shallow respirations
Reduced urine output (less than 25 ml/
hour)
Tachycardia

DIAGNOSTIC TEST RESULTS


Blood tests show elevated potassium,
serum lactate, and BUN levels; increased
urine specific gravity (greater than 1.020)
and urine osmolality; decreased blood pH;
decreased partial pressure of arterial oxygen,

313419NCLEX-RN_Chap03.indd 51

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increased partial pressure of arterial carbon


dioxide; and possible decreased Hb and HCT
(if the client is bleeding).
Gastroscopy, aspiration of gastric contents
through a nasogastric tube, and X-rays identify internal bleeding sites.
ABG analysis reveals metabolic acidosis.

NURSING DIAGNOSES
Ineffective tissue perfusion:
Cardiopulmonary, renal, cerebral, GI
Decreased cardiac output
Deficient fluid volume

TREATMENT
Blood and fluid replacement
Control of bleeding

INTERVENTIONS AND RATIONALES


Management of hypovolemic shock necessitates prompt, aggressive supportive measures
and careful assessment and monitoring of
vital signs. Follow these priorities:
Check for a patent airway and adequate
circulation. If blood pressure and heart rate
are absent, start CPR to prevent irreversible
organ damage and death.
Record blood pressure, pulse rate,
peripheral pulses, respiratory rate, and pulse
oximetry every 15 minutes and monitor the
ECG continuously. A systolic blood pressure
lower than 80 mm Hg usually results in inadequate coronary artery blood flow, cardiac
ischemia, arrhythmias, and further complications of low cardiac output. When blood
pressure drops below 80 mm Hg, increase
the oxygen flow rate and notify the physician immediately. A progressive drop in blood
pressure accompanied by a thready pulse generally signals inadequate cardiac output from
reduced intravascular volume.
Insert large-bore (14G) I.V. catheters
and infuse normal saline or lactated Ringers
solution and appropriate blood products, as
indicated, to correct fluid volume deficit.
Insert an indwelling urinary catheter to
measure hourly urine output. If output is less
than 30 ml/hour in adults, increase the fluid
infusion rate but watch for signs of fluid overload, such as an increase in PAWP. Notify the
physician if urine output doesnt improve. An
osmotic diuretic such as mannitol (Osmitrol)

I better back
up and study
assessment
findings again. Early
recognition of signs
and symptoms of
hypovolemic shock
are necessary to
prevent irreversible
damage.

4/8/2010 7:01:47 PM