Pr ese n te d b y G r ou p B

HYPOVOLEMIC
SHOCK
Ro me ro , D e in ie lle I n g ri d
Ro me ro , P a mela
Ru f in o , L e slie K ri zte l
Sa d d i, E ll a Jo y ce
Sa n ch e z, D ia n e
Sa n to s, A lf re d D o min ic
 Case 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.
 Case Scenario cont.
An endoscopy showed a 25- × 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 tid. 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

II/VI 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.

1.What may have
precipitated
C.W.’s The ulcer mixed with warfarin could have caused

gastrointestinal him to bleed.

(GI) bleeding?
 Red stool: caused by bleeding in the intestines

2. From his history that transfers to stools or vomit Dizzinesss: can be

caused by anemia from the bleed

and assessment, Disoriented: caused by anemia and loss of blood

identify 5 signs and flow to the brain in more severe cases Low BP:

caused by reduced blood flow due to severe

symptoms of GI bleeding

bleeding and loss of

Epigastric tenderness: caused by the damage the

bleed has caused to the intestines.

blood volume
3. What is the
most serious
potential Hypovolemic shock
complication of
C.W.’s bleeding?
4. What is the effect of C.W’s blood pressure
on his kidneys?
When the volume of blood is low, arterial cells in the kidneys secrete renin directly into
circulation. Plasma renin then carries out the conversion of angiotensinogen released by the liver
to angiotensin 1. If the kidneys don't have access to the right amount of blood, they are unable to
properly filter the blood or receive enough oxygen to function. Over time these problems from the
lower blood pressure result in the kidneys slowly shutting down, wherein causing fluid retention.
 Case Study progress
C.W. receives a total of 4 units of packed red blood cells (PRBCs), 5 units of fresh frozen plasma
(FFP), and several liters of crystalloids to keep his mean BP above 60. On the second day in the
MICU, his total fluid intake is 8.498 L and output is 3.66 L. His hemodynamic parameters after
fluid resuscitation are pulmonary capillary wedge pressure (PCWP) 30 mm Hg and cardiac output
(CO) 4.5 L/min.
 5. Why will you want to monitor his fluid
status very carefully?
C.W’s PCWP is elevated (30 mmHg). Elevation of PCWP may indicate severe left
ventricular or severe mitral stenosis, leading to pressure may increase in your lungs,
leading to fluid buildup. As a result, blood can back up in your legs, ankles, and feet,
causing edema. As the kidney is not functioning well patient may lead to FVO. This can
overwork the heart and worsen the heart’s condition.
6. List at least six things you will monitor to
assess C.W’s fluid balance.
- Edema

- Lung sounds

- Weight

- I&O

- JVD

- Ascites
7. Explain the purpose of the FFP for C.W.

FFP will help increase O2 carrying capacity and

reduce the effects of anemia he may be

experiencing.
Case Study progress:

As soon as you get a

chance, you review
C.W.’s admission
laboratory results.
 8. After examining the lab results, do you have any
concerns with C.W.’s electrolyte levels? Explain your
answer.
Potassium is extremely high which can be fatal. He already has a history of

heart conditions and MI so a spike in his potassium could complicate his heart

further. This could also mean his kidneys are not functioning well enough to

filter out extra potassium. His WBC count is also high indicating an

inflammatory response.
9. In view of the The diagnostic test that would be performed

previous lab
would be. The glomerular filtration rate (GFR) is a
blood test that checks how well the kidneys are

results, what working. Also the ECG, The ECG provides

information about electrolyte imbalances, this is
diagnostic test will because it is noninvasive and can assess

be performed and cardiomyopathy, valvular disorders, left ventricular

functions, etc. As discussed above, hyperkalemia can
why? cause slowed ventricular conduction.
10. Evaluate this
ECG strip, and
note the effect of This ECT strip shows that the QT interval is not equal to or

any electrolyte less than one-half the distance of the RR interval. The QT

interval represents the time required for ventricular

imbalances. depolarization andrepolarization; may be prolonged by

medications, electrolyte disturbances, and subarachnoid

hemorrhage.
11. Why do you
think the BUN and His BUN and Cr are both high which indicate that his
kidneys are not functioning properly and my not be
creatinine are getting perfused well.

elevated?
12. What do the low hemoglobin (Hgb) and hematocrit (Hct)
levels indicate about the rapidity of C.W.’s blood loss?

The low levels of H + H would indicate the patient lost a lot of blood

due to the bleeding ulcer due to him taking Coumadin. Coumadin is an

anticoagulant, which doesn’t allow for blood to clot as fast and increases

the chances of bleeding in anyone taking it.

13. What is the explanation for the prolonged
prothrombintime/intervention normalized ratio (PT/INR)?

Due to patient history of having AFIB and taking Coumadin, his PT/INR
will be longer than normal ranges due to the therapeutic effect of the

medication. Normal finding for PT is 10-13 seconds and INR is >2 for
patients not on anticoagulation therapy. The patient’s level read PT: 23.4

and INR: 4.2

14. What will be a. Hold the warfarin dose.
b. Avoid injections as much as possible.
your response to c. Obtain an order for aspirin if needed for pain.

the prolonged d. Monitor C.W. for signs and symptoms of

bleeding.
PT/INR? Select all e. Prepare to administer a STAT dose of
that apply. protamine sulfate.
15. What safety • Make sure the patient knows what signs and
precautions should symptoms to look for increased bleeding.
you initiate in • Avoid activities that may cause bleeding or

light of his bruising.

• Brush and shave gently.
prolonged PT and
INR?
16. How do you Explain to the patient that the elevated WBC
explain the count is likely from him getting his ulcer

elevated WBC cauterized as this would activate an

inflammatory response.
count?
Thank You!