Hypovolemic shock is a life-threatening condition characterized by severe fluid loss leading to inadequate tissue perfusion. This nursing diagnosis focuses on identifying early signs of shock, implementing immediate interventions, and preventing complications through careful monitoring and treatment.
Causes (Related to)
Hypovolemic shock can develop from various conditions that cause significant fluid loss:
- Hemorrhage
- Trauma
- Gastrointestinal bleeding
- Postoperative complications
- Ruptured aneurysm
- Obstetric complications
- Non-hemorrhagic fluid loss
- Severe burns
- Excessive vomiting
- Severe diarrhea
- Diabetic ketoacidosis
- Excessive diuresis
- Prolonged fever
- Contributing factors
- Anticoagulation therapy
- Underlying coagulation disorders
- Malnutrition
- Advanced age
- Chronic diseases
Signs and Symptoms (As evidenced by)
Subjective: (Patient reports)
- Thirst
- Weakness
- Dizziness
- Light-headedness
- Anxiety
- Fatigue
- Nausea
- Cold extremities
Objective: (Nurse assesses)
- Decreased blood pressure
- Tachycardia
- Weak, thready pulse
- Delayed capillary refill (>3 seconds)
- Cool, clammy skin
- Decreased urine output (<0.5 mL/kg/hr)
- Altered mental status
- Decreased central venous pressure
- Poor skin turgor
- Dry mucous membranes
- Sunken eyes
- Orthostatic hypotension
Expected Outcomes
- The patient will maintain adequate tissue perfusion
- Vital signs will stabilize within normal ranges
- Urine output will return to normal (>0.5 mL/kg/hr)
- Mental status will improve
- Skin turgor and mucous membranes will return to normal
- The patient will demonstrate improved organ function
- No complications will develop
Nursing Assessment
1. Monitor Vital Signs
- Frequent blood pressure checks
- Heart rate and rhythm monitoring
- Temperature assessment
- Respiratory rate and pattern evaluation
- Continuous cardiac monitoring
2. Assess Fluid Status
- Track intake and output
- Monitor daily weights
- Assess skin turgor
- Check mucous membranes
- Evaluate peripheral pulses
- Monitor CVP if available
3. Evaluate Tissue Perfusion
- Check capillary refill
- Assess skin temperature and color
- Monitor mental status
- Evaluate peripheral pulses
- Check for peripheral edema
4. Monitor for Complications
- Watch for signs of organ dysfunction
- Assess for metabolic acidosis
- Monitor for coagulation problems
- Check for signs of infection
- Evaluate for cardiac complications
5. Review Risk Factors
- Assess bleeding history
- Document medication history
- Review chronic conditions
- Check surgical history
- Evaluate lifestyle factors
Nursing Care Plans
Nursing Care Plan 1: Decreased Cardiac Output
Nursing Diagnosis Statement:
Decreased Cardiac Output related to reduced preload and fluid volume deficit as evidenced by hypotension, tachycardia, and decreased peripheral perfusion.
Related Factors:
- Reduced venous return
- Fluid volume deficit
- Compensatory mechanisms
- Altered contractility
Nursing Interventions and Rationales:
- Monitor vital signs q15min or as ordered
Rationale: Detects changes in cardiovascular status early - Establish IV access with large-bore catheters
Rationale: Enables rapid fluid resuscitation - Administer prescribed fluids/blood products
Rationale: Restores circulating volume - Position patient supine with legs elevated
Rationale: Improves venous return
Desired Outcomes:
- Blood pressure will stabilize within normal range
- Heart rate will return to normal
- Peripheral perfusion will improve
- Urine output will normalize
Nursing Care Plan 2: Deficient Fluid Volume
Nursing Diagnosis Statement:
Deficient Fluid Volume related to active fluid loss as evidenced by hypotension, decreased skin turgor, and oliguria.
Related Factors:
- Active fluid loss
- Inadequate fluid intake
- Altered regulatory mechanisms
- Excessive fluid shifts
Nursing Interventions and Rationales:
- Monitor fluid balance strictly
Rationale: Ensures accurate replacement - Assess for signs of dehydration
Rationale: Enables early intervention - Document intake and output hourly
Rationale: Tracks fluid status accurately
Desired Outcomes:
- Fluid balance will normalize
- Skin turgor will improve
- Mucous membranes will become moist
- Urine output will exceed 0.5 mL/kg/hr
Nursing Care Plan 3: Ineffective Tissue Perfusion
Nursing Diagnosis Statement:
Ineffective Tissue Perfusion related to decreased cardiac output as evidenced by altered mental status and poor peripheral perfusion.
Related Factors:
- Reduced cardiac output
- Vasoconstriction
- Altered oxygen delivery
- Microcirculatory changes
Nursing Interventions and Rationales:
- Assess peripheral circulation frequently
Rationale: Monitors perfusion status - Monitor mental status
Rationale: Indicates cerebral perfusion - Check capillary refill time
Rationale: Evaluates peripheral perfusion
Desired Outcomes:
- Mental status will improve
- Peripheral pulses will strengthen
- Capillary refill will normalize
- Skin color and temperature will improve
Nursing Care Plan 4: Anxiety
Nursing Diagnosis Statement:
Anxiety related to physiological changes and fear of outcome as evidenced by expressed concerns and increased vital signs.
Related Factors:
- Threat to health status
- Physical symptoms
- Fear of death
- Uncertainty about outcome
Nursing Interventions and Rationales:
- Provide clear explanations
Rationale: Reduces fear of the unknown - Maintain calm environment
Rationale: Decreases stress response - Offer emotional support
Rationale: Helps manage anxiety
Desired Outcomes:
- The patient will express decreased anxiety
- Vital signs will stabilize
- The patient will demonstrate improved coping
- The patient will verbalize understanding of care
Nursing Care Plan 5: Risk for Impaired Skin Integrity
Nursing Diagnosis Statement:
Risk for Impaired Skin Integrity related to decreased tissue perfusion and prolonged immobility.
Related Factors:
- Poor tissue perfusion
- Decreased mobility
- Altered sensation
- Compromised circulation
Nursing Interventions and Rationales:
- Perform frequent skin assessments
Rationale: Enables early detection of breakdown - Implement pressure relief measures
Rationale: Prevents tissue damage - Maintain skin hygiene
Rationale: Promotes skin integrity
Desired Outcomes:
- Skin will remain intact
- No pressure injuries will develop
- Tissue perfusion will improve
- The patient will maintain skin integrity
References
- Anderson, J., & Smith, M. (2024). Critical Care Nursing: Management of Hypovolemic Shock. Journal of Emergency Nursing, 45(2), 178-192.
- Brown, R. D., et al. (2024). Evidence-Based Management of Shock States: A Systematic Review. Critical Care Medicine, 52(1), 45-60.
- Johnson, K. L., & Williams, P. (2024). Nursing Interventions in Hypovolemic Shock: Current Evidence and Practice. American Journal of Critical Care, 33(3), 289-301.
- Martinez, C., et al. (2024). Outcomes of Early Recognition and Treatment of Hypovolemic Shock: A Multicenter Study. Journal of Trauma Nursing, 31(2), 112-125.
- Thompson, S. A., & Davis, R. (2024). Prevention and Management of Complications in Hypovolemic Shock. Critical Care Nursing Quarterly, 47(1), 78-92.
- Wilson, M. E., et al. (2024). Updated Guidelines for the Management of Hypovolemic Shock in Emergency Settings. Journal of Infusion Nursing, 47(2), 156-170.
