Name: Alaa Tarek Farag Mustafa

ID: A20000124

Hypovolemic shock(non-hemorrhagic)
Definition:
Hypovolemic shock is a medical emergency that happens when your body loses too much blood or fluid. It

makes it very difficult for your heart to beat efficiently and can lead to organ failure.
Hypovolemic shock is a life-threatening condition that
results when you lose more than 15 percent of your
body’s blood or fluid supply and your heart function is
impaired. It can occur due to any type of fluid loss, for
example, as a result of dehydration or diarrhea.

Severe fluid loss makes it difficult for the heart to

pump enough blood to your body. As the fluid loss
increases, hypovolemic shock can lead to organ
failure. This requires immediate emergency medical attention.

Etiology
Non-hemorrhagic hypovolemic shock
can be due to one of the following
etiologies: 
Gastrointestinal Losses
A GI source of hypovolemic shock is
the leading source. The gastrointestinal
tract usually secretes between 3 to 6
liters of fluid daily. However, most of
this fluid gets reabsorbed, and only 100
to 200 mL is lost in the stool. Volume
depletion occurs when the GI secretion
exceeds the reabsorbed. This fluid loss
occurs in the presence of intractable
vomiting, diarrhea, bowel obstruction,
or external drainage via stoma or
fistulas.
Renal Losses
Renal losses of salt and fluid can lead to hypovolemic shock. The kidneys usually excrete sodium and water in a
manner that matches intake. Diuretic therapy and osmotic diuresis from hyperglycemia can lead to excessive
renal sodium and volume loss. In addition, several tubular and interstitial diseases beyond the scope of this
article cause severe salt-wasting nephropathy.
Skin Losses
Excessive fluid loss can also occur from the skin. In a hot and dry climate, skin fluid losses can be as high as 1
to 2 liters/hour. Patients with a skin barrier interrupted by burns or other skin lesions also can experience
significant fluid losses that lead to hypovolemic shock.
Third-Space Sequestration
Sequestration of fluid occurs when intravascular fluid leaves the interstitial compartment leading to effective
intravascular volume depletion and hypovolemic shock. Third-spacing of fluid can occur in intestinal
obstruction, pancreatitis, burn, post-operatively, obstruction of a major venous system, or any other pathological
condition that results in a massive inflammatory response.

Pathophysiology
Hypovolemic shock results from depletion of intravascular volume, whether by extracellular fluid loss or blood
loss. The pre-shock stage is characterized by compensatory mechanisms with increased sympathetic tone
resulting in increased heart rate, increased cardiac contractility, and peripheral vasoconstriction. Due to the
increased sympathetic activity, the early changes in vital signs seen in hypovolemic shock with the loss of 10%
body volume include an increased diastolic blood pressure with narrowed pulse pressure. The net result is
normal or mildly elevated blood pressure.
As volume status continues to decrease, specifically when it is 25 to 30% of the effective blood volume patient
gets into a shock state with a drop in systolic blood pressure, tachycardia, and oliguria. As a result, oxygen
delivery to vital organs cannot meet oxygen demand. Here cells switch from aerobic to anaerobic metabolism,
resulting in lactic acidosis. As sympathetic drive increases, blood flow is diverted from other organs to preserve
blood flow to the heart and brain. This blood flow diversion propagates tissue ischemia and worsens lactic
acidosis. If untreated, this will lead to hemodynamic compromise, refractory acidosis, and a further reduction in
cardiac output, leading to a multiorgan failure (MOF) and, eventually, death.
Clinical presentation
For the non-hemorrhagic hypovolemic shock due to fluid losses, possible GI, renal, open wounds, skin, or third-
spacing as a cause of extracellular fluid loss. Symptoms of hypovolemic shock can be related to volume
depletion, electrolyte imbalances, or acid-base disorders that accompany hypovolemic shock.
Patients with volume depletion may complain of thirst, muscle cramps, and/or orthostatic hypotension. Severe
hypovolemic shock can result in mesenteric and coronary ischemia that can cause abdominal or chest pain. In
addition, agitation, lethargy, or confusion may result from brain mal-perfusion.

Although relatively non-sensitive and nonspecific, a physical exam can help determine the presence of
hypovolemic shock. Physical findings suggestive of volume depletion include dry mucous membranes,
decreased skin turgor, and low jugular venous distention. Tachycardia and hypotension can be seen along with
decreased urinary output. Patients in shock can appear cold, clammy, and cyanotic.

Treatment and treatment outcomes

Once at a hospital, a person suspected of having hypovolemic shock will receive fluids or blood products via
an intravenous (IV) line, to replenish the blood loss and improve circulation.
 Treatment revolves around:
 controlling loss of fluid and blood
 replacing what’s been lost
stabilizing damage that both caused and resulted from the hypovolemic shock
treating the injury or illness that caused the shock, if possible
Treatments may includeTrusted Source:
 blood plasma transfusion
 platelet transfusion
 red blood cell transfusion
 intravenous crystalloids
Doctors may also administer medications that increase the heart’s pumping strength to improve circulation and
get blood where it’s needed. These include:
o dopamine
o dobutamine
o epinephrine
o norepinephrine
Antibiotics may be administered to prevent septic
shock and bacterial infections. Close cardiac monitoring
will determine the effectiveness of the treatment you
receive.
 Case study

he wife of C.W., a 70-year-old man, brought him to the

emergency department (ED) at 0430. She told the ED triage
nurse that he had diarrhea for the past
2 days and that last night he had a lot of "dark red" diarrhea.
When he became very dizzy, disoriented, and weak this
morning, she decided to bring him to
the hospital. C.W.'s vital signs (VS) in the ED were 70/-
(systolic blood pressure [SBP] 70, diastolic blood pressure
[DBP] inaudible), pulse rate 110,
respiratory rate 22, oral temperature 99.1
°
F (37.3
°
C). A 16-gauge IV catheter was inserted, and a lactated Ringer's
infusion was started. The triage nurse
learned C.W. has had idiopathic dilated cardiomyopathy for
several years. The onset was insidious, but the cardiomyopathy
is now severe. His last cardiac
catheterization showed an ejection fraction of 13%. He has
frequent problems with heart failure (HF) because of the
cardiomyopathy. Two years ago, he had
a cardiac arrest that was attributed to hypokalemia. He has a
long history of hypertension and arthritis. He had atrial
fibrillation in the past, but it has been
under control recently. Fifteen years ago he had a peptic ulcer.
Endoscopy showed a 25- x 15-mm duodenal ulcer with
adherent clot. The ulcer was cauterized, and C.W. was admitted
to the medical intensive care unit
(MICU) for treatment of his volume deficit. You are his
admitting nurse. As you are making him comfortable, Mrs. W.
gives you a paper sack filled with the
bottles of medications he has been taking: enalapril (Vasotec) 5
mg PO bid, warfarin (Coumadin) 5 mg/day PO, digoxin
(Lanoxin) 0.125 mg/day PO,
potassium chloride 20 mEq PO bid, and diclofenac (Voltaren)
50 mg PO lid. As you connect him to the cardiac monitor, you
note he is in sinus tachycardia.
Doing a quick assessment, you find a pale man who is sleepy
but arousable and slightly disoriented. He states he is still dizzy
and feels weak and anxious
overall. His BP is 98/52, pulse is 118, and respiratory rate 26.
You hear S3 and S4 heart sounds and a grade IINI systolic
murmur. Peripheral pulses are all
2+, and trace pedal edema is present. Capillary refill is slightly
prolonged. Lungs are clear. Bowel sounds are present, mid-
epigastric tenderness is noted,
and the liver margin is 4 cm below the costal margin. Has not
yet voided since admission. Rates his pain level as "2." A
Swan-Ganz pulmonary artery
catheter and a peripheral arterial line are inserted.
he wife of C.W., a 70-year-old man, brought him to the
emergency department (ED) at 0430. She told the ED triage
nurse that he had diarrhea for the past
2 days and that last night he had a lot of "dark red" diarrhea.
When he became very dizzy, disoriented, and weak this
morning, she decided to bring him to
the hospital. C.W.'s vital signs (VS) in the ED were 70/-
(systolic blood pressure [SBP] 70, diastolic blood pressure
[DBP] inaudible), pulse rate 110,
respiratory rate 22, oral temperature 99.1
°
F (37.3
°
C). A 16-gauge IV catheter was inserted, and a lactated Ringer's
infusion was started. The triage nurse
learned C.W. has had idiopathic dilated cardiomyopathy for
several years. The onset was insidious, but the cardiomyopathy
is now severe. His last cardiac
catheterization showed an ejection fraction of 13%. He has
frequent problems with heart failure (HF) because of the
cardiomyopathy. Two years ago, he had
a cardiac arrest that was attributed to hypokalemia. He has a
long history of hypertension and arthritis. He had atrial
fibrillation in the past, but it has been
under control recently. Fifteen years ago he had a peptic ulcer.
Endoscopy showed a 25- x 15-mm duodenal ulcer with
adherent clot. The ulcer was cauterized, and C.W. was admitted
to the medical intensive care unit
(MICU) for treatment of his volume deficit. You are his
admitting nurse. As you are making him comfortable, Mrs. W.
gives you a paper sack filled with the
bottles of medications he has been taking: enalapril (Vasotec) 5
mg PO bid, warfarin (Coumadin) 5 mg/day PO, digoxin
(Lanoxin) 0.125 mg/day PO,
potassium chloride 20 mEq PO bid, and diclofenac (Voltaren)
50 mg PO lid. As you connect him to the cardiac monitor, you
note he is in sinus tachycardia.
Doing a quick assessment, you find a pale man who is sleepy
but arousable and slightly disoriented. He states he is still dizzy
and feels weak and anxious
overall. His BP is 98/52, pulse is 118, and respiratory rate 26.
You hear S3 and S4 heart sounds and a grade IINI systolic
murmur. Peripheral pulses are all
2+, and trace pedal edema is present. Capillary refill is slightly
prolonged. Lungs are clear. Bowel sounds are present, mid-
epigastric tenderness is noted,
and the liver margin is 4 cm below the costal margin. Has not
yet voided since admission. Rates his pain level as "2." A
Swan-Ganz pulmonary artery
catheter and a peripheral arterial line are inserted.
he wife of C.W., a 70-year-old man, brought him to the
emergency department (ED) at 0430. She told the ED triage
nurse that he had diarrhea for the past
2 days and that last night he had a lot of "dark red" diarrhea.
When he became very dizzy, disoriented, and weak this
morning, she decided to bring him to
the hospital. C.W.'s vital signs (VS) in the ED were 70/-
(systolic blood pressure [SBP] 70, diastolic blood pressure
[DBP] inaudible), pulse rate 110,
respiratory rate 22, oral temperature 99.1
°
F (37.3
°
C). A 16-gauge IV catheter was inserted, and a lactated Ringer's
infusion was started. The triage nurse
learned C.W. has had idiopathic dilated cardiomyopathy for
several years. The onset was insidious, but the cardiomyopathy
is now severe. His last cardiac
catheterization showed an ejection fraction of 13%. He has
frequent problems with heart failure (HF) because of the
cardiomyopathy. Two years ago, he had
a cardiac arrest that was attributed to hypokalemia. He has a
long history of hypertension and arthritis. He had atrial
fibrillation in the past, but it has been
under control recently. Fifteen years ago he had a peptic ulcer.
Endoscopy showed a 25- x 15-mm duodenal ulcer with
adherent clot. The ulcer was cauterized, and C.W. was admitted
to the medical intensive care unit
(MICU) for treatment of his volume deficit. You are his
admitting nurse. As you are making him comfortable, Mrs. W.
gives you a paper sack filled with the
bottles of medications he has been taking: enalapril (Vasotec) 5
mg PO bid, warfarin (Coumadin) 5 mg/day PO, digoxin
(Lanoxin) 0.125 mg/day PO,
potassium chloride 20 mEq PO bid, and diclofenac (Voltaren)
50 mg PO lid. As you connect him to the cardiac monitor, you
note he is in sinus tachycardia.
Doing a quick assessment, you find a pale man who is sleepy
but arousable and slightly disoriented. He states he is still dizzy
and feels weak and anxious
overall. His BP is 98/52, pulse is 118, and respiratory rate 26.
You hear S3 and S4 heart sounds and a grade IINI systolic
murmur. Peripheral pulses are all
2+, and trace pedal edema is present. Capillary refill is slightly
prolonged. Lungs are clear. Bowel sounds are present, mid-
epigastric tenderness is noted,
and the liver margin is 4 cm below the costal margin. Has not
yet voided since admission. Rates his pain level as "2." A
Swan-Ganz pulmonary artery
catheter and a peripheral arterial line are inserted.
he wife of C.W., a 70-year-old man, brought him to the
emergency department (ED) at 0430. She told the ED triage
nurse that he had diarrhea for the past
2 days and that last night he had a lot of "dark red" diarrhea.
When he became very dizzy, disoriented, and weak this
morning, she decided to bring him to
the hospital. C.W.'s vital signs (VS) in the ED were 70/-
(systolic blood pressure [SBP] 70, diastolic blood pressure
[DBP] inaudible), pulse rate 110,
respiratory rate 22, oral temperature 99.1
°
F (37.3
°
C). A 16-gauge IV catheter was inserted, and a lactated Ringer's
infusion was started. The triage nurse
learned C.W. has had idiopathic dilated cardiomyopathy for
several years. The onset was insidious, but the cardiomyopathy
is now severe. His last cardiac
catheterization showed an ejection fraction of 13%. He has
frequent problems with heart failure (HF) because of the
cardiomyopathy. Two years ago, he had
a cardiac arrest that was attributed to hypokalemia. He has a
long history of hypertension and arthritis. He had atrial
fibrillation in the past, but it has been
under control recently. Fifteen years ago he had a peptic ulcer.
Endoscopy showed a 25- x 15-mm duodenal ulcer with
adherent clot. The ulcer was cauterized, and C.W. was admitted
to the medical intensive care unit
(MICU) for treatment of his volume deficit. You are his
admitting nurse. As you are making him comfortable, Mrs. W.
gives you a paper sack filled with the
bottles of medications he has been taking: enalapril (Vasotec) 5
mg PO bid, warfarin (Coumadin) 5 mg/day PO, digoxin
(Lanoxin) 0.125 mg/day PO,
potassium chloride 20 mEq PO bid, and diclofenac (Voltaren)
50 mg PO lid. As you connect him to the cardiac monitor, you
note he is in sinus tachycardia.
Doing a quick assessment, you find a pale man who is sleepy
but arousable and slightly disoriented. He states he is still dizzy
and feels weak and anxious
overall. His BP is 98/52, pulse is 118, and respiratory rate 26.
You hear S3 and S4 heart sounds and a grade IINI systolic
murmur. Peripheral pulses are all
2+, and trace pedal edema is present. Capillary refill is slightly
prolonged. Lungs are clear. Bowel sounds are present, mid-
epigastric tenderness is noted,
and the liver margin is 4 cm below the costal margin. Has not
yet voided since admission. Rates his pain level as "2." A
Swan-Ganz pulmonary artery
catheter and a peripheral arterial line are inserted.
he wife of C.W., a 70-year-old man, brought him to the
emergency department (ED) at 0430. She told the ED triage
nurse that he had diarrhea for the past
2 days and that last night he had a lot of "dark red" diarrhea.
When he became very dizzy, disoriented, and weak this
morning, she decided to bring him to
the hospital. C.W.'s vital signs (VS) in the ED were 70/-
(systolic blood pressure [SBP] 70, diastolic blood pressure
[DBP] inaudible), pulse rate 110,
respiratory rate 22, oral temperature 99.1
°
F (37.3
°
C). A 16-gauge IV catheter was inserted, and a lactated Ringer's
infusion was started. The triage nurse
learned C.W. has had idiopathic dilated cardiomyopathy for
several years. The onset was insidious, but the cardiomyopathy
is now severe. His last cardiac
catheterization showed an ejection fraction of 13%. He has
frequent problems with heart failure (HF) because of the
cardiomyopathy. Two years ago, he had
a cardiac arrest that was attributed to hypokalemia. He has a
long history of hypertension and arthritis. He had atrial
fibrillation in the past, but it has been
under control recently. Fifteen years ago he had a peptic ulcer.
Endoscopy showed a 25- x 15-mm duodenal ulcer with
adherent clot. The ulcer was cauterized, and C.W. was admitted
to the medical intensive care unit
(MICU) for treatment of his volume deficit. You are his
admitting nurse. As you are making him comfortable, Mrs. W.
gives you a paper sack filled with the
bottles of medications he has been taking: enalapril (Vasotec) 5
mg PO bid, warfarin (Coumadin) 5 mg/day PO, digoxin
(Lanoxin) 0.125 mg/day PO,
potassium chloride 20 mEq PO bid, and diclofenac (Voltaren)
50 mg PO lid. As you connect him to the cardiac monitor, you
note he is in sinus tachycardia.
Doing a quick assessment, you find a pale man who is sleepy
but arousable and slightly disoriented. He states he is still dizzy
and feels weak and anxious
overall. His BP is 98/52, pulse is 118, and respiratory rate 26.
You hear S3 and S4 heart sounds and a grade IINI systolic
murmur. Peripheral pulses are all
2+, and trace pedal edema is present. Capillary refill is slightly
prolonged. Lungs are clear. Bowel sounds are present, mid-
epigastric tenderness is noted,
and the liver margin is 4 cm below the costal margin. Has not
yet voided since admission. Rates his pain level as "2." A
Swan-Ganz pulmonary artery
catheter and a peripheral arterial line are inserted.
Mrs. H.S. is a 75 yr old widow who was brought into the ED by her neighbor. In the morning she had seen
bright red blood in her stool, which she contributed to her hemorrhoids. She continued with her normal routine
including shopping and gardening, but in the evening she could no longer ignore the bleeding and called her
neighbor who insisted on driving her to the hospital because she looked pale and was cold to the touch. She
does not smoke or drink. ‘he has arthritis and takes aspirin as needed for pain, sometimes up to 10 tablets a
day. Her BP was 90/60 and her HR was 105 bpm lying down. While she is upright her BP is 75/45 and HR 135.
The source of the blood was determined to be from diverticula in the colon, which had stopped bleeding by the
time of the colonoscopy. She was given a blood transfusion and admitted for observation. In the morning, her
color had returned, she no longer felt light-headed, and both supine and standing BP were normal. She was
discharged with instructions to take it easy and to stop taking aspirin. She was referred for a follow-up
regarding her arthritis and pain management.

SOAP Analysis:

Subjective The patient suffers from bright red blood in her stool, which she contributed to

her hemorrhoids. she looked pale and was cold to the touch.

Objective Her BP was 90/60 and her HR was 105 bpm lying down. While she is upright

her BP is 75/45 and HR 135. The source of the blood was determined to be

from diverticula in the colon

Assessment Depending on the cinical presentation, her BP and diverticula in the colon ,her

sudden complications are due to hypovolemic shock.

Plan She was given blood transfusion as Rapid intervention to restore the blood

volume and she was asked to observe the symptoms recovery .

Case Study 10 - Hypovolemia/Hypovolemic Shock

+
Class: Med Surg II
Scenario
The wife of C.W., a 70-year-old man, brought him to the
emergency department (ED) at 0430. She told the ED triage
nurse that he had diarrhea for the past
2 days and that last night he had a lot of "dark red" diarrhea.
When he became very dizzy, disoriented, and weak this
morning, she decided to bring him to
the hospital. C.W.'s vital signs (VS) in the ED were 70/-
(systolic blood pressure [SBP] 70, diastolic blood pressure
[DBP] inaudible), pulse rate 110,
respiratory rate 22, oral temperature 99.1
°
F (37.3
°
C). A 16-gauge IV catheter was inserted, and a lactated Ringer's
infusion was started. The triage nurse
learned C.W. has had idiopathic dilated cardiomyopathy for
several years. The onset was insidious, but the cardiomyopathy
is now severe. His last cardiac
catheterization showed an ejection fraction of 13%. He has
frequent problems with heart failure (HF) because of the
cardiomyopathy. Two years ago, he had
a cardiac arrest that was attributed to hypokalemia. He has a
long history of hypertension and arthritis. He had atrial
fibrillation in the past, but it has been
under control recently. Fifteen years ago he had a peptic ulcer.
Endoscopy showed a 25- x 15-mm duodenal ulcer with
adherent clot. The ulcer was cauterized, and C.W. was admitted
to the medical intensive care unit
(MICU) for treatment of his volume deficit. You are his
admitting nurse. As you are making him comfortable, Mrs. W.
gives you a paper sack filled with the
bottles of medications he has been taking: enalapril (Vasotec) 5
mg PO bid, warfarin (Coumadin) 5 mg/day PO, digoxin
(Lanoxin) 0.125 mg/day PO,
potassium chloride 20 mEq PO bid, and diclofenac (Voltaren)
50 mg PO lid. As you connect him to the cardiac monitor, you
note he is in sinus tachycardia.
Doing a quick assessment, you find a pale man who is sleepy
but arousable and slightly disoriented. He states he is still dizzy
and feels weak and anxious
overall. His BP is 98/52, pulse is 118, and respiratory rate 26.
You hear S3 and S4 heart sounds and a grade IINI systolic
murmur. Peripheral pulses are all
2+, and trace pedal edema is present. Capillary refill is slightly
prolonged. Lungs are clear. Bowel sounds are present, mid-
epigastric tenderness is noted,
and the liver margin is 4 cm below the costal margin. Has not
yet voided since admission. Rates his pain level as "2." A
Swan-Ganz pulmonary artery
catheter and a peripheral arterial line are inserted.