Nursing Diagnosis, Care Plan, and Interventions for Hypovolemic Shock- A Student’s Guide
Introduction
Hypovolemic shock is a medical emergency that occurs when there is a sudden, significant loss of blood or fluids. This can happen because of injury, burns, or vomiting. Bleeding disorders and many severe infections can also cause it.
When this happens, the heart becomes weak and unable to pump enough oxygen-rich blood around the body to meet energy production (metabolism) and other bodily processes. The person may feel faint due to low levels of oxygen in the blood cells (hypoxia).
They also might have cold skin because their skin temperature regulation isn’t working well. If left untreated, it will lead to death from organ failure – usually within minutes or hours if no treatment is given.
This post will provide information about the symptoms of hypovolemic shock and how to treat it using nursing diagnosis, care plan, and interventions to nursing students.
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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students, for learning purposes only, and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.
Definition of Hypovolemic Shock
The medical definition of hypovolemic shock is when the volume of circulating blood drops below 70% of normal, typically because of a sudden loss of fluid. The body responds to hypovolemic shock by trying to restore blood volume. If this is not successful, the blood pressure drops below 90 mmHg, and hypoxia occurs (the tissues do not receive enough oxygen).
What is Hypovolemia?
Hypovolemia is the depletion of blood and fluid in the circulatory system. It occurs when there is a decrease in circulating volume within the vascular system, leading to insufficient oxygenation of tissue cells.
Hypovolemia is often the result of excessive bleeding (excessive blood loss) or fluid shifts. Fluid shifts can occur from gastrointestinal bleeding, vomiting, diarrhea, or inadequate intake and use of oral fluids.
The cardiovascular system must adjust to accommodate the decrease in circulating blood volume by increasing the heart rate and arterial pressure. The kidneys help by decreasing the amount of urine excreted.
Blood is pumped from the heart to all body parts through blood vessels called arteries and arterioles (smaller branches off the arteries). The blood then returns to the heart via veins and venules (smaller branches off the veins). To compensate for decreased circulating blood volume, the heart increases its pumping rate (tachycardia) and maintains arterial pressure. The kidneys help by decreasing the amount of urine excreted.
The body decreases peripheral vascular resistance to increase blood flow through the already constricted vessels, resulting in a drop in both systolic and diastolic blood pressure. Blood volume decreases further, causing a reduction in blood pressure. As blood pressure drops, compensatory mechanisms attempt to reverse this trend by constricting the arteriole and increasing heart rate (tachycardia).
This results in an increase of oxygen-rich blood flow to the central region of the body (peripheral vasoconstriction) in an attempt to meet the needs of the organs that require oxygen (brain, heart, liver, kidneys). This causes peripheral tissues to become hypoxic.
Types of Hypovolemic shock
There are two types of hypovolemic shock: Cardiogenic and Noncardiogenic.
Cardiogenic shock results from inadequate cardiac output, usually due to myocardial infarction (heart attack).
Noncardiogenic shock occurs when there is an excessive loss of fluid from the vascular system. The most common causes of noncardiogenic shock include:
-Prolonged hemorrhage (excessive blood loss) from trauma, surgery, or peptic ulcer disease; hypovine ketoacidosis in a diabetic patient; and rapid shifts in fluid volume such as those experienced with severe burns.
Common Causes of Hypovolemic Shock
Trauma is one of the leading causes of hypovolemic shock, which includes:
- Gunshot wounds
- Blunt trauma – injuries like whiplash
- Blunt trauma can result from walking into a door frame or getting hit by an automobile. It can also occur with falls, wrestling, martial arts, hockey, or football.
Hemorrhage is the most common cause of shock. Shock can also lead to severe anemia.
Risk Factors for Hypovolemic Shock:
- Major surgery as a post-surgical complication.
- A direct blow to the body causes massive bleeding (i.e., the platelet count is low, which means less than 90,000).
- Uncontrolled bleeding from a wound or injury (doctors recommend no more than 2 to 4 oz. of blood should be lost at any given time).
- Severe vomiting and/or diarrhea for prolonged periods of time.
Complications for hypovolemic shock pertain to injuries or bleeding from the chest, arms, belly (abdomen), and legs, plus taking medications that can lower blood pressure (hypotension). It could also be due to having a heart attack, an allergic reaction, and serious burns.
Signs and Symptoms Associated with Hypovolemic Shock
Most people experience the following signs and symptoms when in hypovolemic shock:
Cool, pale skin (pallor) – As blood vessels dilate in an attempt to deliver oxygen-rich blood to the core region of the body, skin color changes from pink (in health) to pale.
Blood pressure falls rapidly – Systolic can fall as low as 40 mm Hg; diastolic BP less than 60 mm Hg. Respiratory rate increases.
Cool, clammy skin (peripheral vasoconstriction) due to decreased blood flow (poor peripheral perfusion); altered mental status;
Other Signs and Symptoms
- Feelings of lightheadedness, dizziness, nausea, fatigue, and confusion
- Increased heart rate
- Shortness of breath
- Rapid breathing
- Decreased urine output and increased thirst
- Weakness, paralysis in the lower extremities (due to loss of blood flow and oxygen to muscle tissue).
- Blood loss can be massive or minimal. Even a small amount of blood loss over a short time can lead to shock if not treated quickly.
Late signs of hypovolemic shock are evident when the client becomes pale, cold, diaphoretic (sweating), paralyzed, or unconscious. The nurse will quickly notify the doctor as symptoms demand close observation, and/or immediate intervention may be needed.
Hypovolemic Shock Nursing Diagnosis
The nursing diagnosis for hypovolemic shock include;
- Decreased cardiac output
- Pain
- Altered nutrition, less than body requirements related to the inability of the cardiovascular system to meet oxygen needs and maintain normal blood flow through vasodilation.
- Risk for ineffective breathing pattern related to respiratory muscle fatigue
- Disturbed Body Image: Peripheral
- Impaired Skin Integrity related to impaired peripheral pulses
- Decreased tissue perfusion related to inadequate oxygen supply.
- Risk for Injury related to hypotension and altered mental status
- Urinary Retention is related to decreased urinary output.
Explanation of Hypovolemic Shock Nursing Diagnosis:
Cardiac output becomes severely compromised due to vasodilation, which decreases blood flow throughout the body. This leads to alterations in oxygenation (altered oxygen supply) and perfusion (decreased blood flow). The nursing diagnosis, decreased cardiac output, states that the patient has decreased blood flow throughout the body.
Pain can accompany any condition which causes shock. It is caused by dysfunctions such as cuts, burns, or other injuries that cause trauma to the soft tissue and body.
The nursing diagnosis of risk for ineffective breathing patterns focuses on this area. The respiratory muscles can become fatigued, which may lead to altered breathing patterns, or shallow breaths that further decrease oxygenation. Hydrogen ion concentration in the blood, also known as pH level, should be maintained between 7.35 and 7.45. It must be kept to avoid acidosis, which can also result in hypovolemic shock.
Disturbed body image is the patient’s perception of his physical condition, including mobility, independence, and appearance. When a person experiences hypovolemic shock, he may have feelings of helplessness and dependency or a feeling of being unhealthy.
Risk for injury includes the patient’s inability to respond appropriately to life-threatening situations. This is a result of altered mental status secondary to shock.
Deficient fluid volume (hypovolemia) would cause decreased tissue perfusion, which is the flow of blood to tissues within the body. This can lead to impaired skin integrity and risk for ineffective thermoregulation.
The risk for urinary retention occurs because shock decreases renal perfusion, resulting in hypoperfusion of nephrons, causing kidney failure (Kidney Nursing Diagnosis). The risk for imbalanced fluid volume (hypovidemia) and disturbed nutrition, less than body requirements, involves the same factors that cause hypovolemic shock.
Clammy skin decreased radial pulse, and altered mental status is signs of shock. Hypovolemic shock may go unnoticed until a life-threatening event occurs.
Hypovolemic Shock Nursing Care Plan
The nursing care plan for hypovolemic shock has three components:
Airway management, breathing exercises, and skincare. The monitoring of vital signs such as heart rate, blood pressure, respiration temperature and urine output is very important. The bladder should be empty if the patient is to receive a Foley catheter in order to monitor urine output.
Airway Management
Airway management includes keeping the airway open by providing oral hygiene measures such as mouth care or denture care as needed. Ensure that the patient is not choking on saliva or food by suctioning the mouth periodically.
Breathing Exercise
The breathing exercises should be implemented so that the patient can learn to control his/her respirations in order to accommodate fluid shifts and increase alveolar ventilation.
Skin Care
Skincare, monitoring for signs of infection includes keeping peripheral body parts such as hands and feet – warm by using the blankets, and monitoring for redness or tenderness to touch.
Other Care Plans
- Monitoring vital signs such as heart rate, blood pressure, respiration temperature, and urine output is very important. The bladder should be empty if the patient is to receive a Foley catheter in order to monitor urine output.
- Monitor the patient’s level of consciousness (i.e., confusion or fatigue) to report immediately to the hospital staff.
- Monitor IV site for infiltration of fluids or blood clots and apply pressure as needed. -Assess skin integrity on peripheral body parts by checking capillary refill, skin color (pallor), sensation, temperature, and bleeding.
- Administer prescribed pain meds to minimize the discomfort and enhance the patient’s comfort.
Nursing Interventions for Hypovolemic Shock
Interventions such as fluid replacement therapy (fluid resuscitation) may be necessary in order to stabilize the patient before they are transferred into an emergency department or intensive care unit.
The main goal is to maintain blood pressure if it drops below 90-60 mmHg and gets IVs running with crystalloids (Lactated Ringer’s solution, normal saline) and/or packed red blood cells (RBCs)
Keep the client calm and lie down with elevated legs. If you can’t get IV access in a central vein, you have to start an IV in the arm or feet area depending on the situation.
It is also important to assess for any other injuries/bruises on the client’s body that can cause excessive bleeding (loss of blood) and keep an eye on other vital signs (e.g., pulse, respiratory rate, and oxygen saturation).
As a nurse, you need to monitor the client’s vital signs for chest pain, shortness of breath, or change in mental status. You need to assess skin color and temperature as well.
Restore circulating volume by providing an external means to rapidly expand the vascular space (i.e., an intraosseous infusion of fluids, plasma, and medications), IV administration of crystalloids or colloids, and close clinical monitoring for changes in cardiovascular status as well as delivery or additional interventions when necessary.
Nursing Interventions for the Underlying Cause of Shock
Nursing interventions for the underlying cause of shock include;
- Encourage oral hydration to maintain adequate fluid volume.
- Administer IV fluids with electrolytes if oral hydration is not possible, and/or shock is severe.
- Monitor blood pressure using a manual cuff or an automated device.
- Oxygenate by using a non-rebreather mask or BiPAP.
- Monitor and record pulse rate, blood pressure, respiratory rate, and saturation.
- Continue to monitor for signs of shock: heart palpitations, hypotension, tachycardia or bradycardia (accelerated or decelerated), cold clammy skin, and altered mental status.
- Assess for pain related to the underlying cause of shock. -Provide emotional support to the patient and family members.
Interventions Directed at Preventing Complications Associated with Hypovolemia
The nurse will assess the client’s vital signs, including;
- Temperature, pulse, and respiration
- Level of consciousness
- Color changes specific to lips or fingernails
- Skin turgor (capillary refill time)
- Bleeding sites
- Pupil size and reactivity (for assessment of hypoxia and perfusion)
- Cardiac rhythm.
The nurse will also assess for signs/symptoms of electrolyte imbalance, including hyperglycemia and acidosis.
The nurse will monitor temperature and peripheral perfusion by assessing capillary refill, noting skin turgor and color, and assessing oxygenation through the observation of respirations.
The nurse will monitor for complications associated with hypovolemic shock, including cardiac dysrhythmias (pulseless electrical activity [PEA], ventricular fibrillation, tachycardia), respiratory arrest, pulmonary edema, pericardial tamponade, seizures and changes in hematocrit (as a marker for volume expansion).
The nurse will provide comfort measures to the client, including;
- Providing a quiet environment
- Administering medications as ordered
- Assisting with family/visitor needs
- Performing therapeutic skincare as appropriate. Cautious movement is warranted as the client may be experiencing pain with movement.
The nurse will provide education to the family/significant others about maintaining homeostasis, recognizing signs and symptoms of hypovolemic shock, and when to notify a physician for further evaluation or resuscitation. The nurse will also discuss interventions that can be performed by family members if they are present.
Preventative Nursing Interventions:
- Monitor and record weight daily
- Recognize trends in vital signs so they can be monitored closely, especially heart rate, blood pressure, and respiratory rate
- Administer prescribed meds regularly
- Ensure that adequate nutrition is provided to the patient
- Maintain normal room temperature.
Assessment After Interventions
After nursing interventions are performed, the nurse should assess for the effectiveness of treatment using tools such as:
- Measure vital signs at least every 2 hours, and record them in the patient’s chart.
- Evaluate for pain using brief assessments such as the 0-10 scale or Numeric Visual Analogue Scale (NVAS).
- Monitor trends in vital signs, especially heart rate, blood pressure, and respiratory rates.
- Monitor trends in laboratory values. These include:
- Sodium
- Potassium
- Carbon dioxide (CO2)
- Electrolytes
- Hematocrit/Hemoglobin
- Blood glucose
- Fibrinogen
- Evaluate hydration status using a urine-specific gravity of 1.015 or greater for adequate intake or urine output of at least 0.5 cc/kg/hr.
- Monitor heart rhythm, especially if the patient is on medications or has a history of heart problems.
- Evaluate for signs of infection related to the cause of shock.
1) Disease: patients with hypovolemic shock often have other serious conditions such as septicemia, pneumonia, myocardial infarction (MI), and trauma.
2) Surgical: Patients may have had surgery recently, leading to shock.
3) Pregnancy: The risk for perinatal mortality is increased in pregnant women with hypovolemia. This risk can be reduced by early recognition and treatment of shock.
Complications of Hypovolemic Shock:
Complications for hypovolemic shock include;
- Cardiovascular collapse (dysrhythmias, bradycardia, peripheral vasoconstriction)
- Respiratory failure from low oxygen levels (pulmonary edema)
- Pulmonary edema is excess fluids being forced into the lungs, making it difficult or painful for one to breathe properly.
- Metabolic acidosis
- Hyperglycemia
- Seizures
- Coma and death
Treatment for Hypovolemic Shock:
Intravenous access via the antecubital fossa or central vein (if not contraindications) is performed by the nurse. Blood products are ordered, and/or plasma transfusions for every 10 cc are given to help add volume to the body and increase blood pressure.
Fluids are given via IV in the largest vein available and are required to be warmed to 98.6 degrees F. The nurse will also assess for lactated Ringer’s solution, which contains glucose (for a rapid energy source). However, consent must be obtained first from physicians or family members before administering.
A blood transfusion may be necessary in severe cases, and fluid replacement solutions containing sugar and electrolytes will help restore body balance.
Blood products packed with red blood cells are given when the client is losing blood rapidly (hemorrhaging or hypovinereraldia). Blood products are also given to replace red blood cells, clotting factors, and platelets (when they have been lost from trauma or surgery).
There are three methods of blood replacement – whole blood, diluted blood, and plasma:
Whole Blood Plasma Crystalloid Colloid
The overall goal is to enhance oxygen delivery, increase the volume of blood and decrease the viscosity of the blood. The latter method also increases the number of red blood cells (RBCs) since each corpuscle contains hemoglobin for carrying oxygen from the lungs to tissues. This will increase their capacity for transferring oxygen even when the blood is not circulating.
This will, in turn, lessen the workload of the cardiovascular system and prevent hypovolemic shock from becoming irreversible. If you are wondering what kind of fluids I would use for this condition, it would be normal saline which is used to treat a variety of conditions: dehydration, burns, hypoglycemia (low blood sugar), dehydration in infants and children, post-surgery, etc.
This is not to be confused with sports drinks! Sports drinks are meant for replacing electrolytes lost during intense physical activity or after strenuous workouts (as opposed to blood loss).
Normal saline contains no minerals, sugars, or proteins; it is a sterile solution that may be used to flush out the kidneys, blood, or other areas of the body. It does not need refrigeration and is available as a 5% volume strength (0.9%) which is isotonic (balanced) with body fluids and can be given intravenously, by mouth, or topically. Normal saline has no calories.
Normal saline will be the best fluid to use in this case since it will replace fluids without introducing any foreign material into the person’s body. This is because normal saline is sterile (contains no bacteria) and does not have calories like a sports drink does!
Summary
Hypovolemic shock is a condition that can be caused by severe blood loss. When this happens, the heart rate and then blood pressure drops quickly. Since there isn’t enough fluid in the body to circulate oxygen, cells start to die. This condition requires immediate medical attention and extensive care if it is not reversed immediately.
The nursing diagnosis for hypovolemic shock would be Ineffective Tissue Perfusion related to decreased Cardiac output as a result of Hypovolemia (Risk).
Possible interventions could include: managing fluids, monitoring electrolytes such as potassium levels and phosphate levels, checking urine output every hour, treating any underlying infection or injury with antibiotics or pain medication, assessing for other conditions like diabetes mellitus, which may affect the treatment plan, and ensuring the patient is comfortable.
Treatment for hypovolemic shock is the same as treatment for shock. A vasopressor (chemical) is used to increase cardiac output and pulse pressure, fluids are given to increase intravascular volume, a blood transfusion may be necessary in severe cases, and fluid replacement solutions containing sugar and electrolytes will help restore the body balance.
Hypovolemic shock is a life-threatening condition. If it is not managed and reversed, the patient may suffer from organ failure due to inadequate cardiac output.
The material presented in this post is intended for educational purposes only. Please consult with your health care provider before deciding on the treatment/care plan for you or any individual.
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