HYPOVOLEMIC SHOCK

Background
Hypovolemic shock is the most common type of shock that is characterized by decreased
intravascular volume. Body fluid in contained in the intracellular and extracellular
compartments. Intracellular fluid accounts for about two thirds of the total body water. The
extracellular body fluid is found in one of two compartments, intravascular (inside blood vessels)
or interstitial (surrounding tissues. The volume of interstitial fluid is about three to four terms
that of intravascular fluid. Hypovolemic shock occurs when there is a reduction in intravascular
volume by 15% to 30%, which represents a loss of 750 to 1,500 ml of blood in a 70-kg (154-lb)
person. The annual incidence of shock of any etiology is 0.3 to 0.7 per 1000, with hemorrhagic
shock being most common in the intensive care unit. Hypovolemic shock is the most common
type of shock in children, most commonly due to diarrheal illness in the developing world.
Hypovolemic shock occurs as a result of either blood loss or extracellular fluid loss.
Hemorrhagic shock is hypovolemic shock from blood loss. Traumatic injury is by far the most
common cause of hemorrhagic shock. Other causes of hemorrhagic shock include
gastrointestinal (GI) bleed, bleed from an ectopic pregnancy, bleeding from surgical intervention,
or vaginal bleeding.
Hypovolemic shock is defined as the rapid fluid loss or blood loss which results in
multiple organ dysfunction due to inadequate circulating blood volume and perfusion. It is
caused by a loss of intravascular fluid which is usually whole blood or plasma. Whole blood loss
from an open wound is an obvious cause for hypovolemic shock. An intravascular volume
depletion may occur with any condition which leads to excessive extracellular fluid loss with or
without loss of plasma protein. Hypovolemic shock is secondary to hemorrhagic shock (rapid
blood loss) which is rare but cause serious complications and mostly occurs in obstetrical
situations. Hypovolemic shock is associated with disorders that cause an underlying
hemodynamic defect of a low intravascular volume and a reduction in myocardial contractility. It
is a consequence of decreased preload due to intravascular volume loss. The decreased preload
diminishes stroke volume, resulting in decreased cardiac output (CO). The systemic vascular
resistance (SVR) is typically increased in an effort to compensate for the diminished CO and
maintain perfusion to vital organs. The early stage of recognition and intervention will help to
prevent death.
Hypovolemic shock is caused by sudden blood or fluid losses within your body. The most
common clinical causes of hypovolemic shock are hemorrhage, vomiting, diarrhea, severe burns,
and excessive sweating. Since arterial blood pressure (BP) is dependent on the CO and SVR,
marked reduction in either of these variables without a compensatory elevation results in
systemic hypotension. In hypovolemic shock, the volume loss is exogenous or endogenous.
Restoration blood volume is both simple and effective if applied before irreversible tissue
damage occurs. The external fluid losses and the internal sequestration will cause reduced
venous return and decreased CO. This leads to set of reflex responses designed to maintain the
oxygen to critical organs such as brain and heart. However, these responses may limit perfusion
of other organs such as gut as to produce necrosis. The consequences of reduced tissue perfusion
are similar in all forms of shock.

FACTORS THAT COULD AFFECT HYPOVOLEMIC SHOCK

The causes of hemorrhagic shock are traumatic, vascular, GI, or pregnancy related, as
follows:
 Traumatic causes can result from penetrating and blunt trauma. Common traumatic
injuries that can result in hemorrhagic shock include the following: myocardial laceration
and rupture, major vessel laceration, solid abdominal organ injury, pelvic and femoral
fractures, and scalp lacerations.
 Vascular disorders that can result in significant blood loss include aneurysms,
dissections, and arteriovenous malformations.
 GI disorders that can result in hemorrhagic shock include the following: bleeding
esophageal varices, bleeding peptic ulcers, Mallory-Weiss tears, and aortointestinal
fistulas.
 Pregnancy-related disorders include ruptured ectopic pregnancy, placenta previa,
and abruption of the placenta. Hypovolemic shock secondary to an ectopic pregnancy is
common. Hypovolemic shock secondary to an ectopic pregnancy in a patient with a
negative urine pregnancy test is rare but has been reported.
 EXPECTED ROS

REVIEW OF SYSTEMS

General Survey

The usual weight of the client is 63kg. , upon hospitalization, the patient’s weight
decreased to 61kg. , appears fatigue upon assessment.

Integumentary System

Skin is fair in color and wrinkled. No scalp lesions and edema.Skin has a normal
temperature when touched. No edema noted. Has a poor skin turgor. Has no history of
any skin allergies. Has a history of chicken pox and measles.

Head, Eyes, Ears, Nose, and Throat (EENT)

No scalp lesions or flaking. No history of any head injuries. Patient is far

sighted.Patient is able to hear whispered words or watch tick. Patient had no history of
 otitis media.No problems upon disseminating various scents.He had a history of
tonsillitis.

Gastrointestinal System

Patient had no complaints of constipation. Patient had no abnormality in

defecating. No abnormal bowel sounds. He had no history of hemorrhoids and rectal
bleeding.

Musculoskeletal System

Patient has hemiplegia.

Neurologic System

Patient is conscious to time, place and people. Has no history of seizure.

Urinary System

Patient urinates 5 times a day. Patient does not experience pain upon voiding.
Color of the urine is amber. Urine transparency is hazy.
Reproductive System (Female)

Patient is satisfied with her sex life. Pt. had no history of of any STDs,
HIV/AIDS.

Hematologic

Patient has diabetes mellitus II and hypertension.

Endocrine
Patient had no history of polyuria and nocturia. No thyroid problem. He had a history of
tonsillitis.
Psychiatric

No signs depression. No history of attempted suicides.

 EXPECTED PHYSICAL EXAMINATION
General Survey

Properly groomed, awake with eyes open and looking at the examiner. Lying on
bed in a semi-fowler’s position and appears fatigue. Hooked with an IVF of PLR 1000ml
at 30gtts/min at right cephalic vein with nasal cannula attached running at 3 liters/min of
oxygen concentration. Oriented to time and place and also oriented to the people around.
Able to recall when and who visits a while ago for immediate memory. Has short term
memory. Ht: 5’4” Wt: 61 kg, Apical pulse: 72bpmResp: 20 cpmTemp: 36.0 ℃ Blood
Pressure: 110/70 mmHg O2 Saturation: 96%
Skin
Inspection
Skin is fair in color and wrinkled. No scalp lesions and edema upon inspection.
Palpation
Skin has a normal temperature of 36.0 ℃ when touched. No edema noted. Has a
poor skin turgor upon palpation.
Head and Face
Inspection
No scalp lesions or flaking. .Smiles, frowns, shows teeth, blows cheeks, and raises
eyebrows as instructed.
Palpation
Patient identifies light touch and sharp touch to forehead, cheek and chin. Head
symmetrically rounded upon palpation.
Eyes

Inspection

Eyebrows sparse with equal distribution. No scaliness noted. Lids brown without
lesions. Sclera without increased vascularity or lesions noted. Palpebral and bulbar
conjunctiva pale without lesions noted. Irises uniformly black. Pupils are round and react
to light and accommodation.

Palpation

No edema noted. No masses noted.

Ears and Nose

Inspection

Auricle without deformity, lumps or lesions. Auricle aligned with outer canthus
of eye about 10 degrees from vertical. Nares patent. No redness, swelling, and abnormal
discharge on the nasal mucosa. Whisper test: Patient is unable to hear whispered words or
watch tick.

Palpation
Auricles and mastoid processes are non-tender. Pinna recoils after it is folded.
Nose is symmetrical and straight upon palpation.

Mouth and Throat

Inspection

Lips are moist pink, smooth and with no lesions. Central facial palsy noted. Use
of dentures on the incisors noted. Tonsils appear to be normal.

Palpation
No palpable nodules noted.
Neck

Inspection

Neck is symmetrical. Trachea is in center placement in midline of neck.

Palpation

Lymph nodes are non-palpable.

Arms, Hands, and Fingers

Inspection

Arms are equal in size and symmetry bilaterally. Skin is fair in color. Three
flexion creases present in palm. Fingernails are finely cut, clean and clear. No clubbing.
Hands are wrinkled.
Palpation

Poor skin turgor and elasticity. Normal temperature when touched. No edema

Thorax and Lungs

Inspection

Posterior lateral diameter is 1:2 ratio. Anterior lateral diameter is 1:2 ratio.
Symmetrical expansion on posterior thorax. Chest symmetry is equal. Shape and
position of sternum is level with ribs. Position of trachea is in midline.

Palpations

No pain or tenderness in the anterior and posterior thorax.No masses noted.

Auscultation

Lungs clear to auscultation on inspiration and expiration.

Breasts (Female)
Inspection
Pendulous breast noted.
Palpation
No palpable nodules noted.
Abdomen
Inspection
Abdomen is uniform in color. No rashes or lesions. No evidence of enlargement of liver
and spleen.
Palpation

Abdomen is soft. No evidence of enlargement of liver and spleen upon palpation

Auscultation

Bowel sounds are normal (15-30 sounds/min).

Legs, Feet and Toes
Inspection
Minor scar located at the anterior fibula. Toenails are finely cut, clean, and clear.
No clubbing. Feet are wrinkled.
Palpation

No edema noted.

Genitalia (Female)

Inspection

Decrease in size and elasticity of labia. Decrease elasticity of vaginal walls.

Muskoloskeletal and Neurologic examination

Inspection

Muscle strength 2/5. No edema noted at both lower extremities. Passive range of motion;
pt. has poor range of motion. No deviations, inflammations, or bony deformities. Hemiplegia
noted. Pt. is weak but awake with eyes open and looking at the examiner; client responds
appropriately. Oriented to time and place and also oriented to people around. Able to recall when
and who visits a while ago for immediate memory. Can recall her name.She has trouble
regaining his memory on what he was doing from the past days. Takes incoming information
appropriately. Right hand: Alternates finger to nose with eyes closed; occasionally tends to hit
opposite side of nose. Rapidly opposes fingers to thumb bilaterally without difficulty. Alternates
pronation and supination of hands rapidly without difficulty.Heel to shin intact bilaterally. Left
hand: has difficulty in moving. Has difficulty in opposing fingers to thumb bilaterally. Cannot
fully alternate pronation and supination of hands rapidly. Pt. cannot walk at the moment as she
is still regaining her strength.

Palpation

Pt. cannot feel sense of touch on the left side of her body.
Cranial Nerve Assessment

Cranial Nerve Name Result

I Olfactory Can smell and can identify what it
is.
II Optic Pt. is far sighted.
III Occulomotor Pupils are round and react to light
and accommodation.

IV Trochlear Both eyes are well coordinated

and moves in unison without
tenderness felt when left and right
eyes moves. Patient lids close
symmetrically.
V Trigeminal Has difficulty moving due to
stroke.
VI Abducens Can move left and right eyeballs
in a moderate manner.
VII Facial Raises her left and right eyebrows
whenever you say something to
her. Can close his both eyes.

VIII Acoustic Pt. clearly hears normal voice

tone.
IX Glossopharyngeal Positive gag reflex
X Vagus Positive swallowing reflex
XI Spinal Accessory Patient can move his neck
XII Hypoglossal Can protrude tongue

Drug Study #1

Generic Name:

dopamine hydrochloride
Brand Name:

Intropin

Dosage:

Route:

IM

Frequency:

Classifications:

Inotropic agents

Mechanism of actions:

Causes norepinephrine release (mainly on dopaminergic receptors), leading to vasodilation of

renal and mesenteric arteries. Also exerts inotropic effects on heart, which increases the heart
rate, blood flow, myocardial contractility, and stroke volume.

Indications:

Shock; hemodynamic imbalance; hypotension; heart failure

Contraindications:

● Hypersensitivity to drug or bisulfites

● Tachyarrhythmias, ventricular fibrillation

● Pheochromocytoma

Adverse Effects:

CNS: headache

CV: palpitations, hypotension, angina,

ECG changes, tachycardia, vasoconstriction, arrhythmias

EENT: mydriasis
GI: nausea, vomiting

Metabolic: azotemia, hyperglycemia

Respiratory: dyspnea, asthma attacks

Skin: piloerection

Other: irritation at injection site, gangrene of extremities (with high doses for prolonged periods
or in occlusive vascular disease)

Nursing Interventions

 Monitor blood pressure, pulse, urinary output, and pulmonary artery wedge pressure during
infusion.
 Inspect I.V. site regularly for irritation. Avoid extravasation.
 Monitor color and temperature of extremities.
 Never stop infusion abruptly, because this may cause severe hypotension. Instead, taper
gradually.
 Drug Study #2

Generic Name:

dobutamine hydrochloride

Brand Name:

Intropin

Dosage:

Route:

Frequency:

Classifications:

Inotropic

Mechanism of actions:

Stimulates beta1-adrenergic receptors of heart, causing a positive inotropic effect that increases
myocardial contractility and stroke volume. Also reduces peripheral vascular resistance,
decreases ventricular filling pressure, and promotes atrioventricular conduction.

Indications:

 Short-term treatment of cardiac decompensation caused by depressed

contractility (such as during refractory heart failure); adjunct in cardiac surgery

Contraindications:

● Hypersensitivity to drug

● Idiopathic hypertrophic subaortic stenosis

Adverse Effects:

CNS: headache

CV: hypertension, hypotension, tachycardia, premature ventricular contractions, angina, palpitations,

nonspecific chest pain, phlebitis
GI: nausea, vomiting

Metabolic: hypokalemia

Respiratory: dyspnea, asthma attacks

Skin: extravasation with tissue necrosis

Other: hypersensitivity reactions

including anaphylaxis

Nursing Interventions

 Monitor ECG and blood pressure continuously during administration.

 Monitor cardiac output, pulmonary capillary wedge pressure, and central venous pressure.
 Monitor fluid intake and output and watch for signs and symptoms of worsening heart failure.
 Assess electrolyte levels. Stay especially alert for hypokalemia.
 Drug Study #3

Generic Name:

nitroglycerin

Brand Name:

Tridil

Dosage:

Route:

Frequency:

Classifications:

Antianginal

Mechanism of actions:

Inhibits calcium transport into myocardial and vascular smooth muscle cells, suppressing
contractions. Dilates main coronary arteries and arterioles, inhibits coronary artery spasm,
increases oxygen delivery to heart, and reduces frequency and severity of angina attacks.

Indications:

 Management and prophylaxis of angina pectoris

 Hypertension during surgery; adjunct in heart failure
 Heart failure associated with acute myocardial infarction (MI)

Contraindications:

 Hypersensitivity to drug, other organic nitrates, nitrites, or adhesives (transdermal form)

 Angle-closure glaucoma
 Orthostatic hypotension
 Hypotension or uncorrected hypovolemia (I.V. form)
 Early MI (S.L. form)
 Increased intracranial pressure (as from head trauma or cerebral hemorrhage)
  Severe anemia
 Pericardial tamponade or constrictive pericarditis
 Concurrent sildenafil therapy

Adverse Effects:

CNS: dizziness, headache

CV: hypotension, syncope

Hematologic: methemoglobinemia

Skin: contact dermatitis (with transdermal or ointment use), rash, exfoliative dermatitis, flushing

Nursing Interventions

 With I.V. use, monitor blood pressure frequently. Titrate dosage to obtain desired results.
 With transdermal use, check for rash or skin irritation.
 Monitor patient for angina relief.
 Drug Study #4

Generic Name:

epinephrine

Brand Name:

Adrenalin

Dosage:

Route:

Frequency:

Classifications:

mydriatic, bronchodilator

Mechanism of actions:

Stimulates alpha- and beta-adrenergic receptors, causing relaxation of cardiac and bronchial
smooth muscle and dilation of skeletal muscles. Also decreases aqueous humor production,
increases aqueous outflow, and dilates pupils by contracting dilator muscle.

Indications:

 Bronchodilation; anaphylaxis; hypersensitivity reaction

 To restore cardiac rhythm in cardiac arrest

Contraindications:

● Hypersensitivity to drug, its components, or sulfites

● Angle-closure glaucoma

● Cardiac dilatation, cardiac insufficiency

● Cerebral arteriosclerosis, organic brain syndrome

● Shock with use of general anesthetics band halogenated hydrocarbons or cyclosporine

● MAO inhibitor use within past 14 days

Adverse Effects:

CNS: nervousness, anxiety, tremor, vertigo, headache, disorientation, agitation,

drowsiness, fear, dizziness, asthenia, cerebral hemorrhage, cerebrovascular accident (CVA)

CV: palpitations,widened pulse pressure, hypertension, tachycardia, angina, ECG changes, ventricular
fibrillation, shock

GI: nausea, vomiting

GU: decreased urinary output, urinary retention, dysuria

Respiratory: dyspnea, pulmonary edema

Skin: urticaria, pallor, diaphoresis, necrosis

Nursing Interventions

 Monitor vital signs, ECG, and cardiovascular and respiratory status. Watch for ventricular
fibrillation, tachycardia, arrhythmias, and signs and symptoms of shock. Ask patient about
anginal pain.
 Assess drug’s effect on underlying problem (such as anaphylaxis or asthma attack), and repeat
dose as needed.
 Monitor neurologic status, particularly for decreased level of consciousness and other signs and
symptoms of cerebral hemorrhage or CVA.
 Monitor fluid intake and output, watching for urinary retention or decreased urinary output.
 Inspect injection site for hemorrhage or skin necrosis.
 Drug Study #5

Generic Name:

pentoxifylline

Brand Name:

Trental

Dosage:

Route:

Frequency:

Classifications:

Hemorrheologic,

xanthine derivative

Mechanism of actions:

Thought to enhance blood flow to the circulatory system by

increasing vasoconstriction and oxygen concentrations.

Indications:

Drug-drug. Anticoagulants, nonsteroidal anti-inflammatory drugs

(NSAIDs): increased risk of bleeding

Antihypertensives: additive hypotension

Theobromide, theophylline: increased

risk of theophylline toxicity

Contraindications:

 Hypersensitivity to drug or methylxanthines (such as caffeine, theophylline, theobromine)

 Recent cerebral or retinal hemorrhage
Adverse Effects:

CNS: agitation, dizziness, drowsiness, headache, insomnia, nervousness, tremor, anxiety, confusion,
malaise

CV: angina, edema, hypotension, arrhythmias

EENT: blurred vision, epistaxis, laryngitis, nasal congestion, sore throat

GI: nausea, vomiting, constipation, diarrhea, abdominal discomfort, belching, bloating, dyspepsia, flatus,
cholecystitis, dry mouth, excessive salivation, anorexia

Hematologic: leukopenia

Respiratory: dyspnea

Skin: rash, urticaria, pruritus, brittle fingernails, flushing, angioedema

Nursing Interventions

● Monitor vital signs and cardiovascular status. Watch for arrhythmias, angina, edema, and
hypotension.

● Frequently monitor prothrombin time and International Normalized Ratio in patients receiving
warfarin

concurrently.

● Assess theophylline level in patients receiving theophylline-containing drugs concurrently.

 Drug Study #6

Generic Name:

norepinephrine bitartrate

Brand Name:

Levophed

Dosage:

Route:

Frequency:

Classifications:

Alpha- and beta adrenergic agonist, cardiac stimulant,

vasopressor

Mechanism of actions:

Stimulates beta1 and alpha1 receptors in sympathetic nervous system, causing

vasoconstriction, increased blood pressure, enhanced contractility, and decreased heart rate

Indications:

 Severe hypotension

Contraindications:

 Concurrent cyclopropane or halothane anesthesia

 Hypotension caused by blood volume deficit (except in emergencies until blood volume
replacement is completed), profound hypoxia or hypercarbia
 Mesenteric or peripheral vascular thrombosis

Adverse Effects:

CNS: headache, anxiety

CV: bradycardia, severe hypertension, arrhythmias

Respiratory: respiratory difficulty

Skin: irritation with extravasation, necrosis

Other: ischemic injury

Nursing Interventions

 Check blood pressure every 2 minutes until desired pressure is achieved. Recheck every 5
minutes for duration of infusion
 Maintain continuous ECG monitoring and blood pressure monitoring.
 Be aware that headache may signal extreme hypertension and overdose.
 Monitor infusion site for extravasation.
 Watch for signs and symptoms of peripheral vascular insufficiency (decreased capillary refill,
pale to cyanotic to black skin color).
 Never leave patient unattended during infusion.
 Drug Study #7

Generic Name:

Brand Name:

Dosage:

Route:

Frequency:

Classifications:

Mechanism of actions:

Indications:

Contraindications:

Adverse Effects:

Nursing Interventions
 Drug Study #8

Generic Name:

Brand Name:

Dosage:

Route:

Frequency:

Classifications:

Mechanism of actions:

Indications:

Contraindications:

Adverse Effects:

Nursing Interventions
 Drug Study #9

Generic Name:

Brand Name:

Dosage:

Route:

Frequency:

Classifications:

Mechanism of actions:

Indications:

Contraindications:

Adverse Effects:

Nursing Interventions
 Drug Study #10

Generic Name:

Brand Name:

Dosage:

Route:

Frequency:

Classifications:

Mechanism of actions:

Indications:

Contraindications:

Adverse Effects:

Nursing Interventions
Pathophysiology
 Pathophysiology
Hypovolemic shock can be caused by external fluid losses, as in traumatic blood loss, or by
internal fluid shifts, as in severe dehydration, severe edema, or ascites. Intravascular volume can
be reduced both by fluid loss and by fluid shifting between the intravascular and interstitial
compartments.
The sequence of events inn hypovolemic shock begins with a decrease in the
intravascular volume. This results in decreased venous return of blood to the heart and
subsequent decreased ventricular filling. Decreased ventricular filling results in decreased stroke
volume (amount of blood ejected from the heart) and decreased cardiac output. When cardiac
output drops, BP drops and tissues cannot be adequately perfused.
 Anatomy & Physiology

The Heart
The heart is a muscular organ about the size of a closed fist that functions as the body’s
circulatory pump. It takes in deoxygenated blood through the veins and delivers it to the lungs
for oxygenation before pumping it into the various arteries (which provide oxygen and nutrients
to body tissues by transporting the blood throughout the body). The heart is located in the
thoracic cavity medial to the lungs and posterior to the sternum. On its superior end, the base of
the heart is attached to the aorta, pulmonary arteries and veins, and the vena cava. The inferior
tip of the heart, known as the apex, rests just superior to the diaphragm. The base of the heart is
located along the body’s midline with the apex pointing toward the left side. Because the heart
points to the left, about 2/3 of the heart’s mass is found on the left side of the body and the other
1/3 is on the right.
Heart Anatomy
A double-layered membrane called the pericardium surrounds the heart like a sac. The outer
layer of the pericardium surrounds the roots of the heart's major blood vessels and is attached by
ligaments to the spinal column and diaphragm. The inner layer of the pericardium is attached to
the heart muscle. A coating of fluid separates the two layers of membrane, letting the heart move
as it beats.
The heart has 4 chambers. The upper chambers are called the left and right atria, and the lower
chambers are called the left and right ventricles. A wall of muscle called the septum separates the
left and right atria and the left and right ventricles. The left ventricle is the largest and strongest
chamber in the heart. Four valves regulate blood flow through your heart:
 The tricuspid valve regulates blood flow between the right atrium and right ventricle. 
 The pulmonary valve controls blood flow from the right ventricle into the pulmonary
arteries, which carry blood to the lungs to pick up oxygen. 
 The mitral valve lets oxygen-rich blood from the lungs pass from the left atrium into the
left ventricle. 
 The aortic valve opens the way for oxygen-rich blood to pass from the left ventricle into
the aorta, the largest artery.
Blood Vessels
Blood vessels are divided into Arteries, Arterioloes, Caplilliaries, Venules, and Veins.

Arteries- The walls (outer

structure) of arteries contain smooth muscle fibre that contract and relax under the instructions of
the sympathetic nervous system. Transport blood away from the heartTransport oxygenated
 NCP #1
Assessment Diagnosis Planning Intervention Rationale Evaluation
Decreased After 8ours of Independent - Sinus Goal met, after
Subjective: cardiac output nursing -Assess the tachycardia and 8hours of
related to intervention the client’s HR and increased arterial nursing
alteration in patient will BP, including BP are seen in intervention the
heart rate or display peripheral the early stages patient was
rhythm hemodynamic pulses. Use to maintain an displaying
stability direct intra- adequate cardiac hemodynamic
arterial output. stability
monitoring as Vasoconstriction
Objective: ordered. may lead to
Vital Signs: unreliable blood
pressure. Pulse
-Jugular vein pressure (systolic
distended minus diastolic)
-Clammy skin decreases in
-Restlessness shock.
-Bradycardia
- Cardiac
- Assess the dysrhythmias
client’s ECG for may occur from
dysrhythmias. the low perfusion
state, acidosis, or
hypoxia, as well
as from side
effects of cardiac
medications used
to treat this
condition.

- Pulses are
- Assess the weak, with
central and reduced stroke
peripheral volume and
pulses. cardiac output.

- Capillary refill
-Assess capillary is slow and
refill time. sometimes
absent.
- Characteristics
- Assess the of a shock
respiratory rate, include rapid,
rhythm and shallow
auscultate breath respirations and
sounds. adventitious
breath sounds
such as crackles
and wheezes.
- Pulse oximetry
-Monitor oxygen is used in
saturation and measuring
arterial blood oxygen
gasses. saturation. The
normal oxygen
saturation should
be maintained at
90% or higher.
As shock
progresses,
aerobic
metabolism stops
and lactic
acidosis occurs,
resulting in the
increased level of
carbon dioxide
and decreasing
pH.

- CVP provides
- Monitor the information on
client’s central filling pressures
venous pressure of the right side
(CVP), of the heart;
pulmonary pulmonary artery
artery diastolic diastolic pressure
pressure and pulmonary
(PADP), capillary wedge
pulmonary pressure reflect
capillary wedge left-sided fluid
pressure, and volumes.
cardiac
output/cardiac
index.
- Restlessness
- Assess for any and anxiety are
changes in the early signs of
level of cerebral hypoxia
consciousness. while confusion
and loss of
consciousness
occur in the later
stages.

- The renal
- Assess urine system
output compensates for
low BP by
retaining water.
Oliguria is a
classic sign of
inadequate renal
perfusion from
reduced cardiac
output.

- Cool, pale,
clammy skin is
- Assess skin secondary to a
color, compensatory
temperature, and increase in
moisture sympathetic
nervous system
stimulation and
low cardiac
output and
desaturation.

- Electrolyte
- Provide imbalance may
electrolyte cause
replacement as dysrhythmias or
prescribed. other
pathological
states.

- Maintaining an
- Administer adequate
fluid and blood circulating blood
replacement volume is a
therapy as priority.
prescribed.

- Shock
- If the client’s unresponsive to
condition fluid replacement
progressively can worsen to
deteriorates, cardiogenic
initiate shock.
cardiopulmonar Depending on
y resuscitation etiological
or other factors,
lifesaving vasopressors,
measures inotropic agents,
according to antidysrhythmics,
Advanced or other
Cardiac Life medications can
Support be used.
guidelines, as
indicated.
DEPENDENT
 NCP #2
Assessment Diagnosis Planning Intervention Rationale Evaluation
Deficient Fluid After 4 hours of - Monitor BP - A common Goal met. After
Volume related nursing for orthostatic manifestation of 4 hours of
Objective:
to active fluid intervention the changes fluid loss is nursing
Vital Sign: volume loss patient will (changes seen postural intervention the
verbalized when changing hypotension. patient was able
BP- 90/50
understanding from a supine to The incidence to verbalized
-T- 35.4 of causative a standing increase with understanding
factors and position). age. Note the of causative
-PR- 130
purpose of following factors and
-RR- 27 individual orthostatic purpose of
therapeutic hypotension individual
-Urine Output:
interventions significances: therapeutic
25ml/hr and Greater than 10 interventions
medications. mm Hg: and
-Cool clammy
circulating medications.
skin blood volume
decreases by
-Capillary refill
20%.
<2sec Greater than 20
to 30 mm Hg
.-HCT 57%
drop: circulating
(increased) blood volume is
decreased by
-Platelet
40%
-28,000-Hgb- - Assess the - Sinus
client’s HR, BP, tachycardia and
7mg/d
and pulse increased
-Poor skin pressure. Use arterial BP are
direct intra- seen in the early
turgor
arterial stages to
-Change in monitoring as maintain an
ordered. adequate cardiac
mental state:
output.
-Restlessness Hypotension
happens as
-Anxious
condition
deteriorates.
Vasoconstriction
may lead to
unreliable blood
pressure. Pulse
pressure
(systolic minus
diastolic)
decreases in
shock.
- Assess for - Confusion,
changes in the restlessness,
level of headache, and a
consciousness. change in the
level of
consciousness
may indicate an
impending
hypovolemic
shock.
- Assess the - Decreased skin
client’s skin turgor is a late
turgor and sign of
mucous dehydration. It
membranes for occurs because
signs of of loss of
dehydration interstitial fluid
-. Monitor the - Accurate
client’s intake measurement is
and output. important in
detecting
negative fluid
balance and
guide therapy.
Concentrated
urine denotes a
fluid deficit.
- Monitor the - CVP provides
client’s central information on
venous pressure filling pressures
(CVP), of the right side
pulmonary of the heart;
artery diastolic pulmonary
pressure artery diastolic
(PADP), pressure and
pulmonary pulmonary
capillary wedge capillary wedge
pressure, and pressure reflect
cardiac left-sided fluid
output/cardiac volumes.
index. Cardiac output
provides an
objective
number to guide
therapy.
- For - It is important
postsurgical to observe an
client, monitor expanding
blood loss hematoma or
(mark skin area, swelling or
weigh dressing increased
to determine drainage to
fluid loss, identify
monitor chest bleeding or
tube drainage). coagulopathy.
- Monitor - Specific
coagulation deficiencies
studies, guide treatment
including INR, therapy
prothrombin
time, partial
thromboplastin
time, fibrinogen,
fibrin split
products, and
platelet count as
ordered.
- Encourage oral - The oral route
fluid intake if supports in
able. maintaining
fluid balance.
- Prepare to - The client’s
administer a response to
bolus of 1 to 2 L treatment relies
of IV fluids as on the extent of
ordered. Use the blood loss.
crystalloid If blood loss is
solutions for mild (15%), the
adequate fluid expected
and electrolyte response is a
balance. rapid return to
normal BP. If
the IV fluids are
slowed, the
client remains
normotensive.
- Initiate IV - Maintaining an
therapy. Start adequate
two shorter, circulating
large-bore blood volume is
peripheral IV a priority. The
lines. amount of fluid
infused is
usually more
important than
the type of fluid
(crystalloid,
colloid, blood).
- Control the - External
external source bleeding is
of bleeding by controlled with
applying direct firm, direct
pressure to the pressure on the
bleeding site. bleeding site,
using a thick dry
dressing
material.
Prompt,
effective
treatment is
needed to
preserve vital
organ function
 and life.
DEPENDENT
- Administer
blood products - Preparing fully
(e.g., packed red crossmatched
blood cells, blood may take
fresh frozen up to 1 hour in
plasma, some
platelets) as laboratories.
prescribed. Consider using
Transfuse the uncrossmatched
client with or type-specific
whole blood- blood until
packed red crossmatched
blood cells. blood is
available. If
type-specific
blood is not
available, type
O blood may be
used for
exsanguinating
clients. If
available, Rh-
negative blood
is preferred,
especially for
women of child-
bearing age.
 NCP #3
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Ineffective After 8 hours of Independent - Particular
Tissue Perfusion nursing - Assess for clusters of signs
related to intervention the signs of and symptoms
Objective: insufficient patient will decreased tissue occur with
knowledge of demonstrate perfusion. differing causes.
disease process increased Evaluation
perfusion as provides a
individually baseline for
appropriate future
comparison.

- Assess for - Restlessness

rapid changes or and anxiety are
continued shifts early signs of
in mental status. cerebral hypoxia
while confusion
and loss of
consciousness
occur in the
later stages.
- Assess - Capillary refill
capillary refill is slow and
sometimes
absent.
- Observe for - Nonexistence
pallor, cyanosis, of peripheral
mottling, cool or pulses must be
clammy skin. reported or
Assess quality managed
of every pulse. immediately.
Systemic
vasoconstriction
resulting from
reduced cardiac
output may be
manifested by
diminished skin
perfusion and
loss of pulses.
Therefore,
assessment is
required for
constant
comparisons
- Record BP - Stable BP is
readings for needed to keep
orthostatic sufficient tissue
changes (drop perfusion.
of 20 mm Hg Medication
systolic BP or effects such as
10 mm Hg altered
diastolic BP autonomic
with position control,
changes). decompensated
heart failure,
reduced fluid
volume, and
vasodilation are
among many
factors
potentially
jeopardizing
- Use pulse optimal BP.
oximetry to - Pulse oximetry
monitor oxygen is a useful tool
saturation and to detect
pulse rate. changes in
oxygen
saturation.
- Review
laboratory data - Blood clotting
(ABGs, BUN, studies are
creatinine, being used to
electrolytes, conclude or
international make sure that
normalized clotting factors
ratio, and stay within
prothrombin therapeutic
time or partial levels. Gauges
thromboplastin of organ
time) if perfusion or
anticoagulants function.
are utilized for Irregularities in
treatment. coagulation may
occur as an
effect of
therapeutic
- Assist with measures.
position - Gently
changes. repositioning
patient from a
supine to
sitting/standing
position can
reduce the risk
for orthostatic
BP changes.
Older patients
are more
susceptible to
such drops of
pressure with
position
Dependent changes.
- Provide
oxygen therapy - Oxygen is
as indicated. administered to
increase the
 amount of
oxygen carried
by available
hemoglobin in
- Administer IV the blood.
fluids as - Sufficient fluid
ordered. intake maintains
adequate filling
pressures and
optimizes
cardiac output
needed for
-Administer tissue perfusion.
medications -to improve
such as tissue perfussion
antiplatelet
agents,
thrombolytics
 NCP #4
Assessment Diagnosis Planning Intervention Rationale Evaluation
anxiety
 NCP #5
Assessment Diagnosis Planning Intervention Rationale Evaluation
 NCP #6
Assessment Diagnosis Planning Intervention Rationale Evaluation
 NCP #7
Assessment Diagnosis Planning Intervention Rationale Evaluation
 NCP #8
Assessment Diagnosis Planning Intervention Rationale Evaluation
 NCP #9
Assessment Diagnosis Planning Intervention Rationale Evaluation
 NCP #10
Assessment Diagnosis Planning Intervention Rationale Evaluation
DIAGNOSTIC TEST