Nursing care plans hypovolemic shock PDF

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Nursing care plans hypovolemic shock Nursing care for patients with Hypovolemic Shock focuses on assisting with treatment aimed at the cause of the shock and restoring intravascular volume. Here are four nursing care plans and nursing diagnoses for hypovolemic shock:    

Decreased Cardiac Output Deficient Fluid Volume Ineffective Tissue Perfusion Anxiety Decreased Cardiac Output Nursing Diagnosis  Decreased Cardiac Output May be related to  Alterations in heart rate and rhythm.  Decreased ventricular filling (preload).  Fluid volume loss of 30% or more.  Late uncompensated hypovolemic shock. Possibly evidenced by  Abnormal arterial blood gasses (ABGs); hypoxemia and acidosis.  Capillary refill greater than 3 seconds.  Cardiac dysrhythmias.  Change in level of consciousness.  Cold, clammy skin.

 Decreased urinary output (less than 30 ml per hour).  Decreased peripheral pulses.  Decreased pulse pressure.  Decreased blood pressure.  Tachycardia. Nursing Interventions

Rationale

Sinus tachycardia and increased arterial BP are seen in the early stages to maintain an adequate cardiac output. Hypotension happens as condition deteriorates. Assess the client’s HR and BP, Vasoconstriction may lead to including peripheral pulses. Use unreliable blood pressure. Pulse direct intra-arterial monitoring as pressure (systolic minus diastolic) ordered. decreases in shock. Older client have reduced response to catecholamines; thus their response to decreased cardiac output may be blunted, with less increase in HR.

Assess the client’s dysrhythmias.

ECG

Cardiac dysrhythmias may occur from the low perfusion state, for acidosis, or hypoxia, as well as from side effects of cardiac medications used to treat this condition.

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

Capillary refill is sometimes absent.

Assess the respiratory rate, rhythm Characteristics

of

slow

and

a shock

and auscultate breath sounds.

include rapid, shallow respirations and adventitious breath sounds such as crackles and wheezes.

Monitor oxygen saturation arterial blood gasses.

Pulse oximetry is used in measuring oxygen saturation. The normal oxygen saturation should be maintained at 90% or higher. As and shock progresses, aerobic metabolism stops and lactic acidosis occurs, resulting in the increased level of carbon dioxide and decreasing pH.

Monitor the client’s central venous pressure (CVP), pulmonary artery diastolic pressure (PADP), pulmonary capillary wedge pressure, and cardiac output/cardiac index.

CVP provides information on filling pressures of the right side of the heart; pulmonary artery diastolic pressure and pulmonary capillary wedge pressure reflect left-sided fluid volumes. Cardiac output provides an objective number to guide therapy.

Restlessness and anxiety are early signs of cerebral hypoxia while confusion and loss of Assess for any changes in the level consciousness occur in the later of consciousness. stages. Older clients are especially susceptible to reduced perfusion to vital organs.

Assess urine output.

The renal system 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 secondary to a compensatory Assess skin color, temperature, and increase in sympathetic nervous moisture. system stimulation and low cardiac output and desaturation. Electrolyte imbalance Provide electrolyte replacement as cause dysrhythmias or prescribed. pathological states.

may other

Administer fluid and blood Maintaining an adequate circulating replacement therapy as prescribed. blood volume is a priority. Fluid warmers keep core temperature. Infusing cold blood is associated with myocardial If possible, use a fluid warmer or dysrhythmias and paradoxical rapid fluid infuser. hypotension. Macropore filtering IV devices should also be used to remove small clothes and debris. If the client’s condition progressively deteriorates, initiate cardiopulmonary resuscitation or other lifesaving measures according to Advanced Cardiac Life Support guidelines, as indicated.

Deficient Fluid Volume Nursing Diagnosis  Deficient Fluid Volume May be related to

Shock unresponsive to fluid replacement can worsen to cardiogenic shock. Depending on etiological factors, vasopressors, inotropic agents, antidysrhythmics, or other medications can be used.

 Active fluid volume loss (abnormal bleeding, diarrhea, diuresis or abnormal drainage).  Internal fluid shifts.  Inadequate fluid intake and/or severe dehydration.  Regulatory mechanism failure.  Trauma. Possibly evidenced by  Capillary refill greater than 3 seconds.  Changes in the level of consciousness.  Cool, clammy skin.  Decreased skin turgor.  Dizziness.  Dry mucous membranes.  Increased thirst.  Narrowing of pulse pressure.  Orthostatic hypotension.  Tachycardia.  Urine output may be normal (>30ml/hr) or as low as 20 ml/hr. Desired Outcomes  Client will be normovolemic as evidenced by HR 60 to 100 beats per minute, systolic BP greater than or equal to 90 mm Hg, absence of orthostasis, urinary output greater than 30ml/hr, and normal skin turgor. Nursing Interventions

Rationale

Monitor BP for orthostatic changes A common manifestation of fluid (changes seen when changing from loss is postural hypotension. The a supine to a standing position). incidence increase with age. Note

the following orthostatic hypotension significances:  Greater than 10 mm Hg: circulating blood volume decreases by 20%.

Assess the client’s HR, BP, and pulse pressure. Use direct intraarterial monitoring as ordered.

Assess for changes in the level of consciousness.

Monitor for possible sources of fluid loss. Assess the client’s skin turgor and mucous membranes for signs of dehydration. Monitor the client’s intake and output.

 Greater than 20 to 30 mm Hg drop: circulating blood volume is decreased by 40%. Sinus tachycardia and increased arterial BP are seen in the early stages to maintain an adequate cardiac output. Hypotension happens as condition deteriorates. Vasoconstriction may lead to unreliable blood pressure. Pulse pressure (systolic minus diastolic) decreases in shock. Older client have reduced response to catecholamines; thus their response to decreased cardiac output may be blunted, with less increase in HR. Confusion, restlessness, headache, and a change in the level of consciousness may indicate an impending hypovolemic shock. Sources of fluid loss may include diarrhea, vomiting, wound drainage, severe blood loss, profuse diaphoresis, high fever, polyuria, burns, and trauma. Decreased skin turgor is a late sign of dehydration. It occurs because of loss of interstitial fluid. Accurate measurement is important in detecting negative fluid balance

and guide therapy. Concentrated urine denotes a fluid deficit. If trauma has occurred, evaluate and document the extent of the client’s injuries; use a primary survey (or another consistent survey method) or ABCs: airway with cervical spine control, breathing, and circulation. Perform a secondary survey after all life-threatening injuries are ruled out or treated. If the only visible injury is an obvious head injury, look for other causes of hypovolemia (e.g, longbone fractures, internal bleeding, external bleeding).

A primary survey helps identify potentially life-threatening injuries. This serves as a quick primary assessment.

A secondary survey uses a methodical head-to-toe inspection. Hypovolemic shock following trauma usually results from hemorrhage.

CVP provides information on filling pressures of the right side of the heart; pulmonary artery diastolic pressure and pulmonary capillary wedge pressure reflect left-sided fluid volumes. Cardiac output provides an objective number to guide therapy. For postsurgical client, monitor It is important to observe an blood loss (mark skin area, weigh expanding hematoma or swelling or dressing to determine fluid loss, increased drainage to identify monitor chest tube drainage). bleeding or coagulopathy. Monitor coagulation studies, including INR, prothrombin time, Specific deficiencies guide partial thromboplastin time, treatment therapy. fibrinogen, fibrin split products, and platelet count as ordered. Obtain a spun hematocrit, and Hematocrit decreased as fluids are reevaluate every 30 minutes to 4 administered because of dilution. hours, depending on the client’s As a rule of thumb, hematocrit decreases 1% per liter of normal ability. Monitor the client’s central venous pressure (CVP), pulmonary artery diastolic pressure (PADP), pulmonary capillary wedge pressure, and cardiac output/cardiac index.

saline solution or lactated Ringer’s used. Any other hematocrit decrease must be evaluated as an indication of continued blood loss. If hypovolemia is a result of severe diarrhea or vomiting, administer Treatment is guided by the cause of antidiarrheal or antiemetic the problem. medications as prescribed, in addition to IV fluids. The oral route supports in Encourage oral fluid intake if able. maintaining fluid balance. Formulas such as the Parkland formula, which follows, guide fluid replacement therapy: If hypovolemia is a result of severe burns, calculate the fluid replacement according to the extent of the burn and the client’s body weight.

 % BSA (body surface area) burned x weight in kg x 4 ml lactated Ringer’s = Total fluid to be infused over 24 hours: half given intravenously over 8 hours and half given over next 16 hours. Prepare to administer a bolus of 1 The client’s response to treatment to 2 L of IV fluids as ordered. Use relies on the extent of the blood crystalloid solutions for adequate loss. If blood loss is mild (15%), the expected response is a rapid fluid and electrolyte balance. return to normal BP. If the IV fluids are slowed, the client remains normotensive. If the client has lost 20% to 40% of circulating blood volume or has continued uncontrolled bleeding, a fluid bolus may produce normotension, but if fluids are slowed after the bolus, BP will deteriorate. Extreme caution is indicated in fluid replacement in older clients. Aggressive therapy may precipitate left ventricular

dysfunction and pulmonary edema. Maintaining an adequate circulating blood volume is a priority. The amount of fluid infused is usually more important than the type of Initiate IV therapy. Start two shorter, fluid (crystalloid, colloid, blood). large-bore peripheral IV lines. The amount of volume that can be infused is inversely affected by the length of the IV catheter; it is best to use large-bore catheters. External bleeding is controlled with firm, direct pressure on the Control the external source of bleeding site, using a thick dry bleeding by applying direct dressing material. Prompt, effective pressure to the bleeding site. treatment is needed to preserve vital organ function and life. If bleeding is secondary to surgery, Surgery may be the only option to anticipate or prepare for a return to fix the problem. surgery. Preparing fully crossmatched blood may take up to 1 hour in some laboratories. Consider using uncrossmatched or type-specific blood until crossmatched blood is Administer blood products (e.g., available. If type-specific blood is packed red blood cells, fresh frozen not available, type O blood may be plasma, platelets) as prescribed. used for exsanguinating clients. If Transfuse the client with whole available, Rh-negative blood is blood-packed red blood cells. preferred, especially for women of child-bearing age. Autotransfusion may be used when there is massive bleeding in the thoracic cavity. For trauma victims with internal These devices are useful to bleeding (e.g., pelvic fracture), tamponade bleeding. Hypovolemia military antishock trousers (MAST) from long-bone fractures (e.g., or pneumatic antishock garments femur or pelvic fractures) may be (PASGs) may be used. uncontrolled by splinting with air

splints. Hare traction splints or MAST and/or PASG trousers may be used to redice tissue and vessel damage from the manipulation of unstable fractures.

Ineffective Tissue Perfusion Nursing Diagnosis  Ineffective Tissue Perfusion May be related to  Decreased stroke volume.  Decreased preload.  Diminished venous return.  Severe blood loss. Possibly evidenced by  Altered mental status.  Cool, clammy skin, pale color.  Cyanosis.  Delayed capillary refill.  Dizziness.  Shallow respirations.  Weak, thready pulse. Desired Outcomes  Client will maintain maximum tissue perfusion to vital organs, as evidenced by warm and dry skin, present and strong peripheral pulses, vitals within patient’s normal range, balanced I&O, absence edema, normal ABGs, alert LOC, and absence of chest pain.

Nursing Interventions

Rationale

Particular clusters of signs and Assess for signs of decreased symptoms occur with differing causes. Evaluation provides a tissue perfusion. baseline for future comparison. Restlessness and anxiety are early signs of cerebral hypoxia while Assess for rapid changes or confusion and loss of continued shifts in mental status. consciousness occur in the later stages. Assess capillary refill.

Capillary refill is sometimes absent.

slow

and

Nonexistence of peripheral pulses must be reported or managed immediately. Systemic Observe for pallor, cyanosis, vasoconstriction resulting from mottling, cool or clammy skin. reduced cardiac output may be manifested by diminished skin Assess quality of every pulse. perfusion and loss of pulses. Therefore, assessment is required for constant comparisons Stable BP is needed to keep sufficient tissue perfusion. Record BP readings for orthostatic Medication effects such as altered changes (drop of 20 mm Hg autonomic control, decompensated systolic BP or 10 mm Hg diastolic heart failure, reduced fluid volume, BP with position changes). and vasodilation are among many factors potentially jeopardizing optimal BP. Use pulse oximetry to monitor Pulse oximetry is a useful tool to detect changes in oxygenen oxygen saturation and pulse rate.

saturation. Review laboratory data (ABGs, BUN, creatinine, electrolytes, international normalized ratio, and prothrombin time or partial thromboplastin time) if anticoagulants are utilized for treatment.

Blood clotting studies are being used to conclude or make sure that clotting factors stay within therapeutic levels. Gauges of organ perfusion or function. Irregularities in coagulation may occur as an effect of therapeutic measures.

Assist with position changes.

Gently 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 changes.

Oxygen is administered to increase Provide oxygen therapy if indicated. the amount of oxygen carried by available hemoglobin in the blood.

Administer IV fluids as ordered.

Anxiety Nursing Diagnosis  Anxiety May be related to  Change in health status.  Fear of death.

Sufficient fluid intake maintains adequate filling pressures and optimizes cardiac output needed for tissue perfusion.

 Unfamiliar environment. Possibly evidenced by  Agitation.  Apprehensive.  Difficulty in concentrating.  Increased awareness.  Increased questioning.  Sympathetic stimulation.  Verbalized anxiety. Desired Outcomes  Client will describe a reduction in level of anxiety experienced.  Client will use effective coping mechanisms. Nursing Interventions

Assess previous mechanism used.

Rationale Anxiety and ways of decreasing perceived anxiety are highly individualized. Interventions are most effective when they are coping consistent with the client’s established coping pattern. However, in the acute care setting these techniques may no longer be feasible.

Assess the client’s level of anxiety.

Shock can result in an acute lifethreatening situation that will produce high levels of anxiety in the client as well as in significant others.

Acknowledge an awareness of the Acknowledgement of the client’s client’s anxiety. feelings validates the client’s feelings and communicates

acceptance of those feelings. Talking about anxiety-producing Encourage the client to verbalized situations and anxious feelings can help the client perceive the situation his or her feelings. in a less threatening manner. Reduce unnecessary external stimuli by maintaining a quite Anxiety may escalate with environment. If medical equipment excessive conversation, noise, and is a source of anxiety, consider equipment around the client. providing sedation to the client. Information helps reduce anxiety. Explain all procedures as Anxious clients unable to appropriate, keeping explanations understand anything more than basic. simple, clear, brief instructions. Maintain a confident, assured manner while interacting with the client. Assure the client and significant others of close, continuous monitoring that will ensure prompt intervention.

The staff’s anxiety may be easily perceived by the client. The client’s feeling of stability increases in a calm and non-threatening atmosphere. The presence of a trusted person may help the client feel less threatened....