Hypovolemic Shock
the body externally or there is shifting of
-What is hypovolemic shock? It
occurs when there is LOW fluid volume
in the intravascular system.
-Hypo: low
-Vol: volume
-Emic: blood
“low blood volume”
-The intravascular system is the space
that contains the volume of blood in a
person’s circulatory system. Therefore,
if there is a decrease in the volume of
blood in a person’s circulatory system,
what does the heart have to pump?
Hardly anything at all!
-If the amount of blood the heart pumps
to the organ/tissues DECREASES, the
cardiac output decreases. This will lead
to decreased tissue perfusion, which will
alter the function of cells. It will limit their
access to oxygen and signs and
symptoms of shock will occur.
-A person needs to lose about 15% or
MORE of their intravascular volume for
hypovolemic shock to occur.
-The average human blood volume is 5
L (exact amount depends on the
person’s size). So, if a person who has
a blood volume of 5 L and loses 1 L of
blood volume (1,000 mL), that would be
20% of their blood volume. This person
would start showing signs and
symptoms of hypovolemic shock.
Causes of Hypovolemic Shock
What can lead to a loss of fluid volume
in the intravascular system?
-Any condition that leads to fluid leaving
fluid within the body that leaves the
intravascular space.
-Relative hypovolemic shock: this is
an INSIDE fluid shift from the
intravascular system (this tends to be
more concealed than absolute)
 Fluids or blood collecting or
leaking inside the body from
internal bleeding, third-spacing of
fluid (severe burns due to
increased capillary
permeability), fracture of long
bones, damage to organs like
the pancreas…example: Cullen or
Turner’s Sign.
 Massive vasodilation from septic
shock
-Absolute hypovolemic shock: this is
an OUTSIDE fluid shift from the
intravascular system that leaves the
body (this tends to be more noticeable
compared to relative)
 Massive bleeding from injury or
surgery
 Excessive fluid loss from oral
(vomiting), GI (diarrhea), GU
(urine), integumentary
(sweating)…..many times this is
caused by a disease process
(diabetes or endocrine disorders)
or illnesses
-Pathophysiology of Hypovolemic
Shock
What is happening in hypovolemic
shock?
-There’s major depletion of volume in
the intravascular system (relative or
-absolute cause) -> this decreases the
amount of venous return to the heart
(this is the amount of blood draining
back to the heart) -> this DECREASES
preload (the amount the ventricles
stretch once their filled with
blood)…they won’t be stretching very
much because there isn’t much fluid to
fill them -> this decreases stroke volume
(the amount of blood pumped by the left
ventricle with each beat -> this
DECREASES CARDIAC OUTPUT (this
is the amount of blood the heart pumps
per minute….4-8 Liters per minute…CO
= HR x SV)
-If cardiac output falls too low, the
amount of blood that should be going to
the organs/tissues cells per minute will
drastically fall.
-And guess what important substance is
in the blood that the cells of the organs
and tissues rely on to survive?
OXYGEN!
-But since the amount of blood that
reaches them is low, the cells won’t
receive enough oxygen to function and
hypoxic injury to the cell can occur.
-The body will attempt to compensate by
activating the sympathetic nervous
system, which will trigger the body’s
built-in survival system.
-Now, based on the percentage of fluid
volume that is lost will determine the
signs and symptoms the patient may
present with and what stage the patient
is likely in.
-Hypovolemic shock can be divided
into four stages or classes, and these
are like the stages of shock we just
reviewed in this series, but these stages
are based on the percentage of fluid
volume loss.
-Remember the numbers: 15, 15-30, 30-
40, 40% and what is happening to the
blood pressure, heart rate, urinary
output, mental status, and the skin.
Class I : <15% of volume loss….up to
750 mL in an adult
-The body can maintain cardiac output
with this volume loss. Patient is mainly
asymptomatic with this class.
 Heart rate within normal limits
(less than 100 bpm)
 Blood pressure, respiratory rate,
within normal limits
 Skin pink, warm, and capillary refill
normal (<2 seconds)
 Normal urinary output (greater
than 30 mL/hr)
 Mental status: normal…may be a
little anxious
Class II: 15-30% of volume
loss….750-1500 mL in an adult
-Cardiac output is starting to fall due to
the volume loss. There is major body
system compensation via the
sympathetic nervous system, renin-
angiotensin system, and the shunting of
blood to vital organs.
 Heart rate will
increase….tachycardia (greater
than 100 bpm)….due to the effects
of the SNS
  Blood pressure decreases but
within normal limits (for now due to
vasoconstriction)
 Respirations increase (mild)…due
to low oxygen level in the body
 Urinary output will start to lower
(20-30 mL/hr)….blood flow is
shunted and body will start to keep
water from aldosterone and ADH
being released due to angiotensin
II
 Skin: cool, clammy, increased
capillary refill >2 seconds…blood
flow diverted to vital organs
 Diminished peripheral pulses
 Mental status: mild anxiety
Class II: 30-40% of volume
loss….1,500-2000 mL in an adult
-The body can’t compensate
anymore…. it’s exhausted! Therefore,
cardiac output falls so low that tissue
perfusion is altered, which causes the
cells that make up the organs to
malfunction…. heart, liver, lungs,
kidneys, brain etc.
 Heart rate increased (significant
tachycardia >120 bpm)
 Respiratory increased….
progressing to respiratory failure
 Hypotension
 Oliguria (<30 mL/hr) ….renal
failure…high BUN and creatinine
 Poor peripheral pulses
 Skin: very cool, mottled, capillary
refill >2 seconds
 Mental status: very anxious and
confused…..acidosis, low oxygen,
and low perfusion to the brain
Class IV: >40% of volume
loss……more than 2,000 mL in an
adult
Death is very near….needs very
dynamic treatment! The body is shutting
down….the fluid loss is SEVERE!
 Significant tachycardia (>140
bpm), increase respiratory
(respiratory failure), severe
hypotension, anuria (no urine
production), mental status: lifeless,
coma
Signs and Symptoms of Hypovolemic
Shock
-Remember it depends on the
percentage of volume loss, but in a
nutshell: tachycardia, hypotension,
cool/clammy skin, weak peripheral
pulses, anxiety, decreased urinary
output…..central venous pressure: low,
PAWP/PCWP: low
Nursing Interventions for
Hypovolemic Shock
-Treatment goals: fluid resuscitation,
correct underlying cause that is leading
to the fluid loss….example:
hemorrhaging: surgery (get the patient
ready for surgery)
Nursing Interventions
-Monitor oxygenation and perfusion
status of patient: place on oxygen, may
need intubation and mechanical
ventilation, what is the patient’s
hemodynamic status? blood pressure,
heart rate, rhythm, tissue perfusion to
organs: mental status, urinary output
(will need catheter insertion to closely
monitor urinary output…UOP needs to
be greater than 30 mL/hr)
-If bleeding, hold firm, direct pressure.
-If showing signs and symptoms of
hypovolemic shock, place in modified
Trendelenburg position (feet at 45’ and
head flat….increases venous return to
heart and cardiac output).
Obtain IV access (at least two IV sites
that are large….18 gauge or bigger in a
large vein like antecubital)…needed for
rapid fluid delivery and other
medications….many patients with
severe hypovolemic shock (especially
ones who are not responding to fluid
treatment) will have a central line and
hemodynamic monitoring to monitor
cardiac output and fluid replacement.
-Collect labs: hgb, hct (blood level),
lactate level (status of cell’s
metabolism), blood gases (acidosis?),
electrolytes, bun, and creatinine
-Severe hypovolemic shock: Central
Venous Pressure (low) and
PAWP/PCWP (low)
Fluids for Hypovolemic Shock
-Crystalloids and colloids Solution are
two types of volume expanders used in
hypovolemic shock: varies depending
on the patient’s status and volume loss
Normal Saline or Lactated
Ringer’s: Isotonic fluids that will add
more fluid to the intravascular
system…increasing preload, stroke
volume, and cardiac output
 most commonly started out on a
crystalloid solution
 watch for fluid volume overload
 If in fluid overload,
hemodynamic monitoring
may show: elevated CVP or
PWCP/PAWP
 Auscultate for fluid in the
lungs…crackles
 Edema, jugular venous
distention
-Remember the 3:1 rule for crystalloid
solutions: For every 1 mL of
approximate blood loss, 3 mL of
crystalloid solution is given.
**** Crystalloid solutions are able to
diffuse through capillary wall, so there is
less fluid that remains in the
intravascular space compared to colloid
solutions.
Colloids:
-Albumin, Hetastarch: made up of
large molecules (example: proteins) that
can’t diffuse through the capillary wall so
more fluid stays in the intravascular
space for longer
 more expensive
 patient can have an anaphylactic
reaction
 monitor for fluid overload
***If giving large amount of fluids, need
to WARM them.
-WHY? If not warmed, it can lead to
hypothermia, and this will alter clotting
enzymes. Keep the patient warm, but
not to the point of sweating.
Blood and Blood Products: Packed
Red Blood Cells, Platelets or Fresh
Frozen Plasma (FFP):
PRBCS: helps replace fluid and
provides the patient with hemoglobin, -
which will carry oxygen to deprived cells
(crystalloids and colloids can’t do
this)….these types of fluid may be used
when the patient is not responding to
crystalloid fluid challenge, experiencing
severe bleeding/severe hypovolemic
shock etc.

Platelets: for uncontrolled bleeding to

help with thrombocytopenia

Fresh Frozen Plasma: for when the

patient needs clotting factors

****monitor for transfusion reaction

with these products