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Hypovolemic Shock NCLEX Review and Nursing Care Plans Hypovolemic shock is a potentially fatal condition characterized by uncontrolled blood or extracellular fluid loss. It is manifested by a drop in blood volume, blood pressure, and urine output of 0.5 ml/kg/hr. Its pathological process develops upon loss of intravascular volume, thereby decreasing blood pressure and venous return. When the intravascular volume is decreased, the physiologic response frequently results in reduced tissue perfusion and impaired cellular metabolism, both shock features. Metabolic acidosis, which impairs mentation, can result from decreased tissue perfusion. Moreover, if hypovolemic shock persists, multiple organ failures may occur. Signs and Symptoms of Hypovolemic ShockHypovolemic shock develops in stages. The symptoms may vary in each stage:
Other physical manifestations of hypovolemic shock include:
Additionally, a patient in shock may be less responsive as a result of alterations in cerebral hemodynamics, which manifest as lethargy, confusion, and restlessness. Causes of Hypovolemic ShockThe most common causes of hypovolemic shock are categorized into four etiologies:
Other renal causes:
Other causes of gastrointestinal etiology include:
Patients with a compromised skin barrier caused by burns or other skin lesions may also have a significant fluid loss, resulting in HS.
Blood loss can also occur as a result of either relative or absolute volume loss.
5. Hemorrhagic. Hemorrhagic shock is a hypovolemic shock caused by blood loss and altered cellular metabolism. Moreover, it can induce hypoxia due to insufficient oxygen delivery. If hypoxia exceeds the usual threshold, insufficient perfusion to the tissues can result in tissue damage, organ malfunction, and death. Other causes of hemorrhagic origin are:
Risk Factors to Hypovolemic Shock
Diagnosis of Hypovolemic Shock
Other tests include:
Treatment of Hypovolemic Shock
Prevention of Hypovolemic Shock
Hypovolemic Shock Nursing DiagnosisNursing Care Plan for Hypovolemic Shock 1Decreased Cardiac Output Nursing Diagnosis: Decreased Cardiac Output related to changes in heart rate and breathing, reduced ventricular filling (preload), a 30 percent or more significant loss in fluid volume, and late unexplained volume depletion secondary to hypovolemic shock as evidenced by low oxygen content in the blood, acidosis, capillary refill time of more than 3 seconds, dysrhythmias of the heart, a shift in one’s level of consciousness, icy, and clammy skin, reduced urinary output (less than 30 ml per hour), reduced peripheral pulses, reduced pulse and blood pressure, and tachycardia. Desired Outcome: The patient will maintain adequate cardiac output, as evidenced by peripheral solid pulses, systolic blood pressure within 20 mm Hg of baseline, heart rate 60 to 100 beats per minute with a regular rhythm, urinary output 30 ml/hr or more significant, warm and dry skin, and an average level of consciousness.
Nursing Care Plan for Hypovolemic Shock 2Deficient Fluid Volume Nursing Diagnosis: Deficient Fluid Volume related to active excessive fluid loss, such as abnormal bleeding, diarrhea, increased urination, unusual drainage, internal fluid transitions, insufficient fluid consumption or severe dehydration, regulatory mechanism breakdown, or trauma secondary to hypovolemic shock as evidenced by capillary refill time higher than three seconds, variations in consciousness, cool or sweaty skin, significantly reduced skin turgidity, lightheadedness, dry mucous membranes, extreme thirst, pulse pressure narrowing, postural hypotension, and palpitations. Desired Outcome: The patient will be normovolemic, as demonstrated by a heart rate of 60 to 100 heartbeats per minute, a systolic blood pressure of equal or greater to 90 mm Hg, the apparent lack of orthostasis, an urine output greater than 30ml per hour and natural skin turgidity.
Nursing Care Plan for Hypovolemic Shock 3Ineffective Tissue Perfusion Nursing Diagnosis: Ineffective Tissue Perfusion related to significantly reduced stroke volume, diminished preload, lowered venous return, and significant blood loss secondary to hypovolemic shock as evidenced by cool, shivery fair-skinned color, cyanosis, deferred capillary refill, lightheadedness, superficial respirations, and a weak pulse. Desired Outcome: As evidenced by dry and warm skin, current and potent peripheral pulses, vitals within the patient’s healthy range, regular intake and output, total lack of edema, standard ABGs, alert loss of consciousness, and absence of breathing difficulties, the patient will preserve optimum tissue perfusion to vital organs.
Nursing Care Plan for Hypovolemic Shock 4Anxiety Nursing Diagnosis: Anxiety related to alterations in health status, apprehension about death, and a distinctive environment secondary to hypovolemic shock as evidenced by uneasiness, irritability, impaired concentration, increased awareness, increased questioning, sympathetic arousal, and articulated anxiety. Desired Outcomes:
Nursing Care Plan for Hypovolemic Shock 5Risk for Impaired Gas Exchange Nursing Diagnosis: Impaired Gas Exchange related to alterations in the oxygen-carbon dioxide stability secondary to hypovolemic shock. As a risk nursing diagnosis, Risk for Impaired Gas Exchange is entirely unrelated to any signs and symptoms since it has not yet developed in the patient, and safety precautions will be initiated instead. Please enable JavaScript Nursing Stat FactsDesired Outcomes:
Nursing ReferencesAckley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon Disclaimer:Please follow your facilities guidelines, policies, and procedures. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. |