What priority nursing interventions should a nurse begin for a patient in shock?
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After reviewing these notes, don’t forget to take the quiz that contains hypovolemic shock NCLEX Questions and to watch the lecture. Show
Lecture on Hypovolemic ShockHypovolemic Shock NCLEX Review Hypo: low Vol: volume Emic: blood “low blood volume” The intravascular system is the space that contains the volume of blood in a person’s circulatory system. Therefore, if there is a decrease in the volume of blood in a person’s circulatory system, what does the heart have to pump? Hardly anything at all! If the amount of blood the heart pumps to the organ/tissues DECREASES, the cardiac output decreases. This will lead to decreased tissue perfusion, which will alter the function of cells. It will limit their access to oxygen and signs and symptoms of shock will occur. A person needs to lose about 15% or MORE of their intravascular volume for hypovolemic shock to occur. The average human blood volume is 5 L (exact amount depends on the person’s size). So, if a person who has a blood volume of 5 L and loses 1 L of blood volume (1,000 mL), that would be 20% of their blood volume. This person would start showing signs and symptoms of hypovolemic shock. Causes of Hypovolemic ShockWhat can lead to a loss of fluid volume in the intravascular system? Any condition that leads to fluid leaving the body externally or there is shifting of fluid within the body that leaves the intravascular space.
Absolute hypovolemic shock: this is an OUTSIDE fluid shift from the intravascular system that leaves the body (this tends to be more noticeable compared to relative)
Pathophysiology of Hypovolemic ShockWhat is happening in hypovolemic shock? -If cardiac output falls too low, the amount of blood that should be going to the organs/tissues cells per minute will drastically fall. And guess what important substance is in the blood that the cells of the organs and tissues rely on to survive? OXYGEN! But since the amount of blood that reaches them is low, the cells won’t receive enough oxygen to function and hypoxic injury to the cell can occur. The body will attempt to compensate by activating the sympathetic nervous system, which will trigger the body’s built-in survival system. Now, based on the percentage of fluid volume that is lost will determine the signs and symptoms the patient may present with and what stage the patient is likely in. Hypovolemic shock can be divided into four stages or classes, and these are like the stages of shock we just reviewed in this series, but these stages are based on the percentage of fluid volume loss. Remember the numbers: 15, 15-30, 30-40, 40% and what is happening to the blood pressure, heart rate, urinary output, mental status, and the skin. Class I : <15% of volume loss….up to 750 mL in an adult The body can maintain cardiac output with this volume loss. Patient is mainly asymptomatic with this class.
Class II: 15-30% of volume loss….750-1500 mL in an adult Cardiac output is starting to fall due to the volume loss. There is major body system compensation via the sympathetic nervous system, renin-angiotensin system, and the shunting of blood to vital organs.
Class II: 30-40% of volume loss….1,500-2000 mL in an adult The body can’t compensate anymore….it’s exhausted! Therefore, cardiac output falls so low that tissue perfusion is altered, which causes the cells that make up the organs to malfunction….heart, liver, lungs, kidneys, brain etc.
Class IV: >40% of volume loss……more than 2,000 mL in an adult Death is very near….needs very dynamic treatment! The body is shutting down….the fluid loss is SEVERE!
*Source: Class/Stage volume loss percentage and amount of volume loss modified from American College of Surgeons Guidelines Signs and Symptoms of Hypovolemic ShockRemember it depends on the percentage of volume loss, but in a nutshell: tachycardia, hypotension, cool/clammy skin, weak peripheral pulses, anxiety, decreased urinary output…..central venous pressure: low, PAWP/PCWP: low Nursing Interventions for Hypovolemic ShockTreatment goals: fluid resuscitation, correct underlying cause that is leading to the fluid loss….example: hemorrhaging: surgery (get the patient ready for surgery) Nursing Interventions Monitor oxygenation and perfusion status of patient: place on oxygen, may need intubation and mechanical ventilation, what is the patient’s hemodynamic status? blood pressure, heart rate, rhythm, tissue perfusion to organs: mental status, urinary output (will need catheter insertion to closely monitor urinary output…UOP needs to be greater than 30 mL/hr) If bleeding, hold firm, direct pressure. If showing signs and symptoms of hypovolemic shock, place in modified Trendelenburg position (feet at 45’ and head flat….increases venous return to heart and cardiac output). Obtain IV access (at least two IV sites that are large….18 gauge or bigger in a large vein like antecubital)…needed for rapid fluid delivery and other medications….many patients with severe hypovolemic shock (especially ones who are not responding to fluid treatment) will have a central line and hemodynamic monitoring to monitor cardiac output and fluid replacement. Collect labs: hgb, hct (blood level), lactate level (status of cell’s metabolism), blood gases (acidosis?), electrolytes, bun, and creatinine Severe hypovolemic shock: Central Venous Pressure (low) and PAWP/PCWP (low) Fluids for Hypovolemic Shock Crystalloids and colloids Solution are two types of volume expanders used in hypovolemic shock: varies depending on the patient’s status and volume loss Normal Saline or Lactated Ringer’s: Isotonic fluids that will add more fluid to the intravascular system…increasing preload, stroke volume, and cardiac output
Remember the 3:1 rule for crystalloid solutions: For every 1 mL of approximate blood loss, 3 mL of crystalloid solution is given. **** Crystalloid solutions are able to diffuse through capillary wall, so there is less fluid that remains in the intravascular space compared to colloid solutions. Colloids:
***If giving large amount of fluids, need to WARM them. WHY? If not warmed, it can lead to hypothermia, and this will alter clotting enzymes. Keep the patient warm, but not to the point of sweating. Blood and Blood Products: Packed Red Blood Cells, Platelets or Fresh Frozen Plasma (FFP): PRBCS: helps replace fluid and provides the patient with hemoglobin, which will carry oxygen to deprived cells (crystalloids and colloids can’t do this)….these types of fluid may be used when the patient is not responding to crystalloid fluid challenge, experiencing severe bleeding/severe hypovolemic shock etc. Platelets: for uncontrolled bleeding to help with thrombocytopenia Fresh Frozen Plasma: for when the patient needs clotting factors ****monitor for transfusion reaction with these products References: American College of Surgeons Division of Education. ACS/ASE Shock Medical Student Core Curriculum [Ebook] (p. 4). Retrieved from https://www.facs.org/~/media/files/education/core%20curriculum/shock.ashx Hypovolemic shock: MedlinePlus Medical Encyclopedia. Retrieved from https://medlineplus.gov/ency/article/000167.htm What are interventions for shock?Lay the person down and elevate the legs and feet slightly, unless you think this may cause pain or further injury. Keep the person still and don't move him or her unless necessary. Begin CPR if the person shows no signs of life, such as not breathing, coughing or moving.
What is the nursing care plan for shock?The nursing care plan in clients with cardiogenic shock involves careful assess the client, observe cardiac rhythm, monitor hemodynamic parameters, monitor fluid status, and adjust medications and therapies based on the assessment data.
Which intervention is a priority for a patient with septic shock?Septic shock is an emergency that is best treated by establishing priorities beforehand. The first priority is early recognition. The earliest recognizable clinical presentation is fever and hyperventilation.
What is the priority intervention for a patient with hypovolemic shock?Three goals exist in the emergency department treatment of the patient with hypovolemic shock as follows: (1) maximize oxygen delivery—completed by ensuring adequacy of ventilation, increasing oxygen saturation of the blood, and restoring blood flow, (2) control further blood loss, and (3) fluid resuscitation.
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