School of Nursing and Allied Medical Sciences

Holy Angel University

Angeles City

Integrative Activity
Module 1: Perioperative Nursing – Nursing Care Mapping

Borja, Monica L
Garcia, Patricia Mae
Ordonez, Orlando
Villena, Ino Justin
NCM1112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolyte, Infectious,
inflammatory and Immunologic Response, Cellular Aberration, Acute and Chronic

Hypovolemic Shock

Hypovolemic shock is a life-threatening condition that results when you lose more than 20
percent (one-fifth) of your body’s blood or fluid supply. This severe fluid loss makes it
impossible for the heart to pump a sufficient amount of blood to your body. Hypovolemic
shock can lead to organ failure.

Nursing Care Mapping

2
1
Decreased Cardiac Output
1. BP 92/43 mmHg
2. PR 117 bpm
1 3. Weak peripheral pulse
4. Cool clammy skin
5. >2sec CRT 3 Ineffective Tissue Perfusion
1. Cool, clammy skin
1
1
2. Appears cyanotic
Deficient Fluid Volume 1
3. BP 92/43 mmHg
1. Cool, clammy skin
4. HR 117 cpm
2. Decreased skin turgor Reasons for seeking Help5 Anxiety 5. >2seconds CRT
3. Dizziness Uncontrolled Bleeding, Post-op
1. CS
Cesarean Section
4. Dry mucuos Priority Assessment: Bleeding
2. Restlessness
membranes Pain 3. Difficulty concentrating 4
5. Increased thirst 1. Facial grimace with pain scale 4. Verbalized nervousness
of 7/10
5. Irritation
2. Protective gesture to avoid
pain in incision site
Relationship of 3. Expresses behavior such as Nursing Diagnosis.
sighing
In 4. Limits movements hypovolemic shock a significant
volume of blood 5. Restlessness and fluid is loss thus the fluid volume
deficit is experienced by the patient. This
deficient in volume in the vascular space initiates a decrease in amount of blood which
circulates back to the heart – the preload, and consequently, decreasing the afterload which is
basically the volume of the blood leaving the heart. This results to a decreased in cardiac output
due to a low stroke volume. To compensate, the heart will try to contract rapidly causing
tachycardia. Since the cardiac output is low the mean arterial pressure decreases which will
cause hypotension leading to ineffective tissue perfusion. The pain and anxiety are direct
consequence to hypovolemic shock but may contribute or be associated to deficit fluid volume
by the body’s coping mechanism like excessive sweating.

Prioritization of Nursing Diagnosis

Uncontrolled bleeding and fluid loss due to hypovolemic shock will result to insufficient
amount of blood carrying oxygen and nutrients to the different organs leading to organ failure.
The body compensate by increasing symphatetic tone – uncreasing heart rate, cardiac
contractility and peripheral vasoconstriction. In prioritization af nursing diagnosis, Abraham
Moslows hierarchy of needs is applied. Which are (1) Biological and Physiological needs, (2)
Safety needs, (3) Love and Belongingness needs, (4) Esteem needs, (5) Self Actualization needs.
Following those the priority nursing intervention is Deficient fluid volume. Controlling fluid
volume in the body helps in resolving blood loss and fluid loss which is the primary cause of the
problem. Second will be Decreased cardiac output to monitor hemodynamic stability of the
patient. To increase the circulation of blood to the periphery, the third priority will be
Ineffective tissue perfusion. Consequently, Acute pain and Anxiety as fourth and fifth.

Problem 1: Deficient Fluid Volume related to abnormal bleeding as manifested by cool clammy
skin.
Goal: Decreased intravascular, interstitial, and intracellular fluid.
Outcome: Client will have a fluid balance as evidenced by HR 60 to 100 beats per minute,
systolic BP greater than or equal to 90 mm Hg, absence of orthostasis, urinary output greater
than 30ml/hr, and normal skin turgor.

The most common cause of hypovolemic shock is blood loss when a major blood vessel
bursts or when you're seriously injured. This is called hemorrhagic shock. Among the causes of
bleeding after cesarean section are atonic hemorrhaging, retained placenta, puerperal fever,
suture failure, and the production of bleeding granulation tissue.

NURSING RATIONALE PATIENT RESPONSES

RESPONSIBILITIES
Monitor BP
Monitor the client’s intake
and output.
Weigh daily with same
scale, and preferably at the
same time of day.
A common manifestation of BP is greater than 90/70
fluid loss is postural
hypotension. The incidence
increase with age.
Accurate measurement is Intake 850/ Output 500 ml
important in detecting
negative fluid balance and
guide therapy
Weight is the best 2lbs in a week
assessment data for possible
fluid volume imbalance.
Encourage oral fluid intake The oral route supports in Normal fluid balance
maintaining fluid balance.

Urge the patient to drink
prescribed amount of fluid.
Administer parenteral fluids
as ordered
Oral fluid replacement is Normal fluid balance
indicated for mild fluid
deficit and is a cost-effective
method for replacement
treatment.
Fluids replacement 1L LRS at 800 cc level.

Administer Vit. K as ordered To prevent excessive Given at 8:15 pm

bleeding by initiating clotting
factor
Review laboratory result for To determine the body will PT result 13 seconds
coagulation, prothrombin able to compensate to the Platelet count = 340, 000 per
time and platelet count problem and to know microliter
whether to administer
additional medication
Review X-ray result To determine the source of Referred to radiology
bleeding

Impression: Client is hydrated and demonstrates lifestyle changes to avoid progression of

dehydration

Problem 2: Decreased Cardiac Output related to decreased preload as manifested by blood

pressure of 92/43 mmHg
Goal: Adequate cardiac output
Outcome: Patient’s PR and BP within normal range

A patient after cesarean section is suffering from hypovolemic shock. This means she is
experiencing profuse bleeding with a blood loss greater than 800 ml. Because we have decrease
in blood volume therefore the amount of blood going back to the heart which is the preload is
also decrease resulting to a decreased cardiac output.

NURSING RESPONSIBILITIES RATIONALE PATIENT RESPONSES

Monitor Vs q4 especially PR
(note the strength pulses) and
BP
Check for peripheral pulses
and capillary refill
Administer fluid
Vital signs serve as baseline BP of 110/70mmHg
data and changes may suggest PR of 85 bpm with strong
aggravation or alleviation of pulse
problem
Weak pulses and slow Weak pulse
capillary refill is present with <3 seconds
reduce cardiac output and
may signify poor circulation
thus oxygenation.
Fluid replacement 1L LRS at 800 cc level.
Administer blood Restore blood volume
Review results of EKG and Determine problems
chest X-ray associated with the heart that
further complicates decreased
cardiac output
Blood is typed and cross-
matched, transfused 2 u PRBC
started at 8:00 pm
Referred to the radiologic
department

Review laboratory result for Potassium for Potential
potassium level, toxicity
ABG ABG for hypoxemia and
BUN and creatine acidosis
BUN and creatinine for
evaluating renal function
Potassium = 3.6 mmol/L
Normal ABG
BUN = 20 mg/dl
Creatinine 1.0 mg/dL

Impression: Patients PR and BP return to normal

Impression: Normal laboratory result

Problem 3: Ineffective tissue perfusion related to interruption of blood flow as manifested by

patient appears cyanotic
Goal: Increase tissue perfusion
Outcome: Demonstrates adequate tissue perfusion as evidenced by palpable peripheral pulses,
warm and dry skin, adequate urinary output, and the absence of respiratory distress

Regular tissue perfusion allows the exchange of gases and nutrients between the blood
and the body's cells. When this exchange is disrupted due to a problem at the exchange point in
the capillaries, it causes oxygen deprivation in the cells and tissues.

INDEPENDENT RATIONALE PATIENT RESPONSES

Assess for signs decreased
tissue perfusion (cyanosis,
weak pulses, capillary refill)
Check for Homan’s sign
Administer IV fluids as
ordered
Administer medications as
prescribed to treat underlying
problem.
Systemic vasoconstriction Peripheral pulse easy to
resulting from reduced palpate.
cardiac output may be <3sec. CRT
manifested by diminished skin
perfusion and loss of pulses
Capillary refill is slow and
sometimes absent. And for
baseline data for comparison
Indication for deep vein (-) Homan’s sign
thrombosis
Sufficient fluid intake 1L LRS at 800 cc level
maintains adequate filling
pressures and optimizes
cardiac output needed for
tissue perfusion.
These medications facilitate Given at 8 am BP of 110/70
perfusion for most causes of
impairment.
Keep an eye on the results of Identify deficiencies and Hgb 7.6 g/dl
CBC needs treatment / response Hct 23%
to therapy.

Review ABG results In a critical care setting pH 7.36

metabolic acidosis is the most pCO2 35 mmHg
frequent acid-base HCO3 22 mmol/L
disturbance and the most O2 sat 98%
common cause is increased
production of the metabolic
acid, lactic acid. Lactic acid is
produced in excess by tissue
cells that are poorly
oxygenated, so metabolic
(lactic) acidosis can arise in
any clinical condition in which
oxygen delivery to tissues is
compromised.

Impression: Patients PR and BP increased to normal level.

Problem no 4: Acute pain related to operative procedure as manifested by painscale of 7/10

Goal: Control Pain
Outcome: Patient’s remain pain scale below 3 on a scale of 0-10 points scale

After delivery, the uterus contracts and shrinks back to its normal size. As this happens,
it can cause some lower abdominal cramps that are referred to as after pains. This pain can feel
like menstrual cramps.

NURSING RESPONSIBILITIES RATIONALE PATIENT RESPONSES

Assess location, nature, and
duration of pain, especially as
it relates to the indication of
CS birth
Instruct relaxation technique
such as positioning for
comfort as possible.
Provide rest periods to
promote relief, sleep,
and relaxation.
Indicate appropriate choice Pain scale of 3/10
of treatment.
May assist in reduction of Position in comfortable
anxiety and tension, promote position with pillow.
comfort and enhance sense
of well-being
One’s experiences of pain The client has rest well
may become exaggerated as
a result of exhaustion. Pain
may result in fatigue, which
may result in exaggerated
pain. A peaceful and quiet
environment may facilitate
rest.
Provide Analgesics as
ordered
Report to the physician when
interventions are
unsuccessful and ineffective.
Coordinate with the dietician
for a specific meal plan
Effectiveness of pain Givent at 7:00 pm
medications must be
evaluated individually
because it is absorbed and
metabolized differently by
patients
Patients who demand pain Pain persist according to the
medications at more patient, referred to the
frequent intervals than doctor
prescribed may actually
require higher doses or more
potent analgesics.
Best diet include fruit, Referred to the dietician.
vegetables and vitamin C –
rich food to lower
inflammation thus resolve
pain.

Impression: Patient painscale decreased to 3/10. Analgesic to PRN

Problem 5: Anxiety related to change in health status as manifested by restlessness and patient
verbalization of nervousness
Goal: Decrease anxiety
Outcome: Client will describe a reduction in level of anxiety experience and appear
appropriately relaxed

Anxiety has different causes; one cause of anxiety may be a medical factor, such as the
symptoms of a different disease, the effects of a medication, or the stress of an intensive
surgery or prolonged recovery like with our case which is a post cesarean section patient.
Anxiety may be related to the release of catecholamines and to mild decreases in cerebral
blood flow. A person who is bleeding briskly also may develop tachypnea and hypotension. As
hypovolemia worsens and tissue hypoxia ensues, increases in ventilation compensate for the
metabolic acidosis produced by increased carbon dioxide production.

NURSING RESPONSIBILITIES RATIONALE PATIENT RESPONSES

Therapeutic communication, Helps to reduce interpersonal Verbalized concerns
especially conveying empathy transmission anxiety, and
shows caring for the patient
or couple.

Comfort Touch Being supportive and Held hand when talking or rub
approachable promotes the back.
communication.

Teach with slow deep- Discovering new coping Facial expressions, gestures,
breathing exercises. methods provides the patient and activity levels that reflect
with a variety of ways to decreased distress.
manage anxiety.
Instruct the patient in the
appropriate use of antianxiety
medications as ordered by the
physician.
Coordinate with the dietician
for a specific meal plan
Refer patient to counseling as
doctor’s ordered.
Impression: Patient responded to anxiety interventions by verbalizing concerns and describing
own anxiety and coping patterns.
Short-term use of antianxiety Vital signs that reflect
medications can enhance baseline or decreased
patient coping and reduce sympathetic stimulation.
physiological manifestations
of anxiety.
Enhancing the diet with foods Referred to the dietician
rich in antioxidants may help
ease the symptoms of anxiety
disorders. 
Standard way of treating Doesn’t anymore show signs
anxiety is psychological of anxiety.
counseling. This can include
cognitive-behavioral therapy
(CBT), psychotherapy, or a
combination of therapies.