NURSING CARE PLAN FOR CLIENT MANIFESTING HYPOVOLEMIC SHOCK RELATED TO SEVERE VEHICULAR ACCIDENT

Date/
Shift Assessment Need Nursing Plan of Care Nursing Intervention Evaluation
Diagnosis
Subjective: After 8 hours of nursing Independent
None intervention the client will
Oct Objective: Nutritional Deficient fluid be able to: 1. Monitor vital signs GOAL MET
11,2021 Altered mental – Metabolic volume related to particularly blood October 11, 2021
status Pattern active volume 1. Manifest fluid pressure for @3PM
7:00am – (Unconscious) loss as evidenced volume at functional orthostatic changes After 8 hour of
3pm by internal level Rationale: nursing intervention
Mechanically bleeding and ( normovolemic) The common manifestation the client
ventilated trauma. and improve skin of fluid loss is orthostatic manifested fluid at
turgor hypotension. Wherein, >10 functional level and
Cool clammy mmHg circulating blood improved skin
skin volume decreases by 20% turgor.
while > than 20-30 mmHg .
Capillary refill drop circulating blood
> 3 seconds volume is decreased by 40%
2. Assess the client’s
Decreased HR, BP, and Pulse
urine output pressure by utilizing
<0.5 ml/kg/hr intra- arterial
monitoring as
Blood pressure ordered.
58/42 mmHg Rationale:
Increased arterial BP and
Rapid, shallow sinus tachycardia
respirations manifestations happen as
condition deteriorates while
vasoconstriction may lead to
unstable blood pressure and
pulse pressure (systolic
minus diastolic decreases in
shock.

3. Assess for changes in

the level of
consciousness

Rationale:
Confusion, restlessness,
headache, and a change in
the level of consciousness
signify an impending
hypovolemic shock.
4. Evaluate and
document the extent
of the client’s injuries
utilizing primary
survey or ABC’s
airway with cervical
spine control,
breathing and
circulation.
Rationale:
When This will help in
identification of potentially
life – threatening injuries and
serves as a quick primary
assessment.
5. Assess client’s skin
 turgor and mucous
membranes for signs
of dehydration.
Rationale:
Decreased skin turgor is a
late sign of dehydration and
it occurred because of loss of
interstitial fluid.
6. Monitor the client’s
intake and output
Rationale:
Accurate measurement is
very important in detection
for negative fluid balance and
guide therapy. Also,
concentrated urine denotes a
fluid deficit.
7. Monitor the client’s
central venous
pressure (CVP),
pulmonary artery
diastolic pressure
(PADP), pulmonary
capillary wedge
pressure and cardiac
output/cardiac index.
Rationale:
Central venous pressure
provides information on
filling pressure of the right
side of the heart; pulmonary
artery diastolic pressure and
pulmonary wedge capillary
wedge pressure reflect left –
sided fluid volumes.

DEPENDENT
1. Prepare to
administer a bolus of
1 to 2 L of IV fluids as
ordered while
utilizing crystalloid
solutions for
adequate fluid and
electrolyte balance.
Rationale:
A fluid bolus may produce
normotension if the client
has lost 20% - 40% of
circulating blood volume or
has uncontrolled bleeding
but if the fluids are slowed
after the bolus, BP will
deteriorate. Encourage
diversion activities like
talking to significant others,
watching TV or listening to
music.

2. Initiate IV
therapy starting with
 two shorter, large
bore peripheral IV
lines.
Rationale:
Maintaining adequate
circulating blood volume is
the priority. The amount of
volume that can be infused is
inversely affected by the
length of IV catheter, thus, it
is best to use large – bore
catheter.

3. Administer blood
products ( packed red
RBC, fresh frozen
plasma, platelets) as
prescribed
Rationale:
Autotransfusion may be
utilized when there is
massive bleeding in the
thoracic cavity.