Hypovolemic Shock Nursing Diagnosis and Nursing Care Plan

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Hypovolemic Shock Nursing Care Plans Diagnosis and Interventions

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 Shock

Hypovolemic shock develops in stages. The symptoms may vary in each stage:

  • Stage 1: Loss of blood volume (0.7L), anxiety, paleness, prolonged capillary time
  • Stage 2: Loss of blood volume (0.7-1.5L), tachycardia, high diastolic pressure, altered mental state, rapid heart rate, decreased urinary output
  • Stage 3: Loss of blood volume (1.5-2L), decreased blood pressure, disorientation
  • Stage 4: Loss of blood volume (>2L), decreased BP, lethargy, disorientation, insufficient or no urinary output, lightheadedness, shallow breathing

Other physical manifestations of hypovolemic shock include:

  • Dry mucous membranes
  • Decreased skin turgor
  • A clammy appearance of the skin
  • Cyanosis
  • Jugular vein distention

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 Shock

The most common causes of hypovolemic shock are categorized into four etiologies:

  1. Renal. Renal losses of sodium and water can lead to hypovolemic shock. Hypernatremia is a condition in which increased sodium secretion occurs in conjunction with increased water secretion due to medications or diuretic use (e.g., osmosis diuresis, loop diuretics). It can also arise from water loss secondary to Diabetes insipidus, which occurs when kidney response to arginine vasopressin (AVP) is impaired.

Other renal causes:

  • Tubular and interstitial diseases
  • Salt wasting nephropathy
  1. Gastrointestinal. This is a case of absolute hypovolemia. Gastrointestinal losses have various causes, but diarrhea, external discharge, and vomiting are the most common. As a result, external and internal shifts cause inadequate tissue perfusion, precipitating shock. Moreover, dehydration, hypochloremia, hyponatremia, and hypokalemia are possible outcomes. Diarrhea-causing conditions can also result in volume loss due to poor intestinal absorption. As with vomiting, electrolyte losses via defecation are expected. Although these two processes are typically self-limiting, symptomatic and intensive care is necessary when the patient becomes hypovolemic.

Other causes of gastrointestinal etiology include:

  • Nasogastric suction
  • Biliary diseases
  • Digestive fistula
  1. Skin. Excessive fluid loss can also occur when skin integrity is impaired. Exposure to hot climates can lead to extreme sweating and insensible losses, such as mouth-breathing, evaporation from the skin, and respiratory loss. Moreover, it can result in water loss of up to 1 L per hour.

Patients with a compromised skin barrier caused by burns or other skin lesions may also have a significant fluid loss, resulting in HS.

  1. Third Spacing. Third spacing is a phenomenon that occurs when fluid migrates to regions that are ordinarily absent of fluid. This condition can arise from pancreatitis, intestinal blockage, embolus, compromised vascular endothelium, and burn victims due to exudates and blister formation. Additionally, relative hypovolemia can occur, resulting in intestinal blockage and tissue due to the pooling of fluids.
  • Intravascular volume depletion. Capillary permeability is the most prevalent cause of electrolyte shifts, resulting in large-scale fluid redistribution from blood vessels into the interstitial space. When fluid shifts occur, the body’s extracellular or intracellular fluid volume is affected.

Blood loss can also occur as a result of either relative or absolute volume loss.

  • Absolute hypovolemia – occurs as a result of hypovolemia due to bleeding, gastrointestinal loss, diuresis, or diabetes insipidus
  • Relative hypovolemia – occurs when fluid exits the circulatory system and enters the extravascular space.

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:

  • Mechanical trauma: Bruising as a result of major cuts or wounds, blunt traumatic injuries sustained in accidents, internal bleeding from abdominal organs
  • Internal bleeding: Ruptured aneurysm, ectopic pregnancy, gastrointestinal bleeding, endometriosis, post-partum bleeding
  • Exteriorization of internal bleeding

Risk Factors to Hypovolemic Shock

  • Age
  • Pre-existing conditions (e.g., bleeding disorders, stenosis, peritonitis, liver disorders)
  • Risk of Injury (e.g., accidents, trauma, major surgeries)
  • Dehydration
  • Burns
  • Prolong hospitalization
  • Pregnancy
  • Medications

Diagnosis of Hypovolemic Shock

  • Medical History. Obtaining a complete medical history enables evaluation of any history of trauma or recent operation. Previous gastrointestinal, renal, third spacing, and skin diseases should be considered.
  • Physical Examination. Patients experiencing HS due to electrolyte imbalances and acid-base disorders typically complain of thirst, muscle cramps, and orthostatic hypotension. Hypovolemic shock, in severe cases, can result in coronary ischemia due to insufficient oxygen delivery, manifesting as abdominal and chest pain. While excessive bleeding is instantly noticeable, internal bleeding may not be.  

Other tests include:

  • Blood tests
  • Ultrasound
  • Echocardiogram
  • CT scan
  • Venous oximetry
  • Lactic acid levels
  • Central Venous Pressure (CVP)
  • Sodium determination
  • Urinalysis

Treatment of Hypovolemic Shock

  • Intravenous fluid therapy. One of the primary goals of addressing HS is restoring fluid loss. Fluid resuscitation remains the therapy of choice to address hypoperfusion and improve oxygen delivery. Crystalloid infusions (isotonic solutions containing electrolytes) are excellent for rapidly restoring tissue perfusion. Fluids should be administered at a fast rate and at sufficient volume. As a result of this procedure, the clinical response can be re-evaluated continuously. 
  • Bleeding control. For severe bleeding, administration of blood components (e.g., blood plasma, red blood cell, platelet) may be necessary. Applying tight dressings, elevating the extremity, and additional pressure can help reduce bleeding.  
  • Catheterization. Set up two IV cannulas with a large-bore needle (16 gauge or more).
  • Treatment of any underlying condition. The physician may address underlying disorders that contribute to hypovolemic shocks, such as gastrointestinal symptoms (e.g., diarrhea, vomiting), bleeding, and dehydration.
  • Oxygen therapy

Prevention of Hypovolemic Shock

  • Early recognition of signs and symptoms. However, it is important to note that there are cases when the healthcare team may not note any warning signs of an impending hypovolemic shock. The symptoms may appear after the patient has developed the condition.
  • For individuals with pre-existing conditions, routinely monitor oxygen saturation, blood pressure, and pulse rate
  • Maintain adequate ventilation and fluid intake.
  • Seek medical treatment and control bleeding in the event of severe trauma.

Hypovolemic Shock Nursing Diagnosis

Nursing Care Plan for Hypovolemic Shock 1

Decreased 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.

Hypovolemic Shock Nursing InterventionsRationale
Examine the patient’s heart rate and blood pressure, and peripheral pulses. As directed, use direct intra-arterial monitoring.      To ensure an appropriate cardiac output, sinus tachycardia and increased arterial blood pressure are seen in the early stages. As the condition worsens, hypotension develops. Vasoconstriction can cause blood pressure to fluctuate. The hypovolemic shock causes a decrease in pulse pressure or systolic minus diastolic. Since older patients have a diminished reaction to catecholamine, their response to cardiac insufficiency may be lessened, resulting in a lower increment in heart rate.  
Examine the patient’s ECG for any abnormal heart rhythms.  Abnormal heart rhythms can occur due to low oxygenation, acidosis, hypovolemia, and a side effect of cardiovascular medicines used to treat this condition.
Examine both the central and peripheral pulses.        The pulses are weak, and the stroke volume and cardiac output are low during hypovolemic shock. That is why monitoring central and peripheral pulses is necessary to avoid further complications.  
Calculate capillary refill time.  Capillary refill time is a helpful and quick metric that measures the intravascular volume status of ill patients, notably those who have hypovolemic conditions.  
Examine the respiratory rate and rhythm, as well as the breath sounds.    A shock is distinguished by quick, shallow respirations and erratic breath sounds such as screeches and wheezes.  
Keep an eye on the patient’s blood oxygen and arterial blood gas levels. Oxygen saturation is measured using pulse oximetry.  The standard oxygen saturation level should be 90 percent or above. As the hypovolemic shock develops, aerobic respiration ceases, and lactic acidosis develops, leading to an increase in carbon dioxide and a decrease in pH levels.    
Examine the state of consciousness of the patient for any changes.  Early symptoms of hypovolemia include restlessness and anxiety, while later symptoms include confusion and loss of consciousness. Patients over 65 years old are particularly prone to diminished perfusion to major organs.    
Analyze urine output.  The kidneys make up the difference for low blood pressure by retaining water. Oliguria is a classic symptom of insufficient renal blood flow due to decreased cardiac output.    

Nursing Care Plan for Hypovolemic Shock 2

Deficient 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.

Hypovolemic Shock Nursing InterventionsRationale
Check the blood pressure for orthostatic changes in the patient. These are changes observed when switching from a lying to a standing position.  Orthostatic hypotension is a common sign of loss of fluid. The prevalence rises with age. Pay attention to the following orthostatic hypotension implications:   More than 10 mm Hg: circulating blood flow is reduced by 20%.A decline of more than 20 to 30 mm Hg reduces the circulating volume of blood by 40%.  
Keep an eye out for probable causes of hypovolemia.    Gastroenteritis, emesis, wound drainage, drastic blood loss, excessive sweating, high fever, excessive urination, burns, and trauma can all cause fluid loss.  
Watch for evidence of dehydration in the patient’s skin turgidity and mucous membranes.  Skin turgidity loss is a hallmark symptom of dehydration. A deficiency of interstitial fluid characterizes it.  
Keep track of the patient’s intake and output.  Precise measurement is essential for identifying deleterious fluid balance and directing therapy. A fluid deficit is indicated by concentrated urine.    In addition to IV fluids, if hypovolemia is caused by severe diarrhea and vomiting, administer antidiarrheal or antiemetic medicines as recommended.        The cause of the problem guides treatment.
If possible, promote oral fluid intake.    The oral route of fluid intake helps to keep fluid balance.  

Nursing Care Plan for Hypovolemic Shock 3

Ineffective 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.

Hypovolemic Shock Nursing InterventionsRationale
Examine for indications of reduced tissue perfusion.  Specific clusters of clinical symptoms occur due to a variety of reasons. The assessment establishes a baseline against which future comparisons can be made.  
Examine the mental status of the patient for abrupt shifts or long-term changes.    Initial symptoms of hypovolemia include disturbance and anxiousness, while relatively late symptoms include ambiguity and loss of consciousness.
Examine the skin for the pale complexion, cyanosis, and discoloration. Each pulse’s quality should be evaluated.  The absence of peripheral pulses must be disclosed or controlled as soon as possible. Decreased cardiac output can cause systemic vascular constriction, manifesting as decreased skin perfusion and pulse loss. As a result, assessment is necessary for consistent comparisons.    
Keep track of the blood pressure readings to check for postural changes such as the drop of 20 mm Hg systolic BP or 10 mm Hg diastolic BP with position changes.    Normal blood pressure is required to maintain adequate tissue perfusion. Medication adverse effects such as modified autonomic control, decompensated heart problems, diminished fluid volume, and dilation of blood vessels are just a few elements that could endanger optimal blood pressure control.
Measure oxygen level and pulse rate using pulse oximetry.        Pulse oximetry is an effective method for detecting adjustments in blood oxygen.
Help the patient with position changes.  The danger of postural blood pressure changes can be reduced by gently repositioning the patient from a lying to a sitting or standing position. Patients over 65 years of age are more vulnerable to pressure drops with position changes.    
If necessary, administer oxygen therapy.  The administration of oxygen supplies oxygen and nutrients carried by available hemoglobin in red blood cells.    
Administer intravenous fluids as directed.  Adequate fluid consumption keeps filling pressures stable and maximizes cardiac function for tissue perfusion.  

Nursing Care Plan for Hypovolemic Shock 4

Anxiety

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:

  • The patient will define a decrease in his or her level of anxiety.
  • The patient will employ appropriate coping strategies.
Hypovolemic Shock Nursing InterventionsRationale
Examine the preceding coping mechanisms of the patient.      Anxiousness and methods for reducing apparent anxiety are unique to each individual. Once intervention strategies are coherent with the patient’s established coping mechanism, they are most efficacious. These strategies, however, may no longer be possible in the clinical setting.
Determine the patient’s level of apprehension.    Distress can result in a severe life-threatening circumstance, causing high anxiety levels in both the patient and significant others.
As the health care provider, make the patients feel that her anxious feelings are acknowledged and not invalidated.      Acknowledging the patient’s feelings and thoughts affirms them and shows acknowledgment of those emotions.  
Encourage the patient to express his or her emotions verbally.    Discussing anxious circumstances and feelings can help the patient comprehend the circumstance as less dangerous.  
Sustaining a quiet environment helps to reduce unneeded external forces.  If the patient is anxious about the hospital devices, consider giving him or her sedatives. Intense discussion, loud sounds, and equipment around the patient may exacerbate anxiety.    
Discuss all procedures as needed using simple explanations.      Anxiety can be reduced with relevant data. Anxious patients can only understand simple, straightforward, relatively short instructions.  
When communicating with the patient, maintain an optimistic, assured demeanor. Assure the patient and significant others that they will be closely monitored and that immediate intervention will be provided.  The patient may be able to sense the healthcare provider’s anxiety. In a calm and safe environment, the patient’s sense of stability grows. The presence of a trustworthy individual may make the patient feel less intimidated.  

Nursing Care Plan for Hypovolemic Shock 5

Risk 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.

Nursing Stat Facts
Nursing Stat Facts

Desired Outcomes:

  • The patients will maintain optimal gas exchange as demonstrated by standard mental health status, unlabored respiratory rate of 12-20 breaths per minute, oxygen saturation results within average limits, venous gas within standard parameters, and patient’s baseline heart rate.
  • The patient has clear lung fields and no signs of respiratory depression.
  • The patient expresses his or her comprehension of oxygen and other treatment strategies.
  • The patient takes part in methods for improving oxygen saturation and in a management regimen appropriate for his or her level of capability or condition.
  • The patient shows signs of resolution or lack of respiratory failure symptoms.
Hypovolemic Shock Nursing InterventionsRationales
Assist the patient in taking deep breaths and coughing with control. Allow the patient to inhale profoundly, hold his or her breath for a few seconds, and cough up to three times with his or her mouth open, narrowing the upper core muscles as sustained.      This method can aid in sputum release and the reduction of cough spasms. Managed coughing uses the diaphragmatic muscles, making the cough more forceful and productive. Patients suffering from hypovolemic shock should have an adequate airway secured.  
Educate family members about disease complications and the importance of keeping a medical treatment plan, including when to contact a doctor.  The family’s understanding of the illness is essential in preventing further complications.  
Help the family of a chronically ill patient.    Patients and their families experience fear and anxiety when their respiratory function is seriously compromised. The nurse’s reassurance can be beneficial.  
Put the patient in a prone position with the upper thorax and pelvis supported and the abdomen was protruding. Keep an eye on the blood oxygen and return if it falls below a certain level. If the patient has multisystem trauma, do not place them in a supine position.  The initial concentration of arterial oxygen has been shown to rise in the supine position, possibly due to higher diaphragm compression and function of the ventral lung areas. Prone posture significantly improves hypoxemia and hypovolemia.  
Examine the home for toxicants that interfere with gas exchange. Assist the patient in making necessary changes to the home setting, such as installing an air purifier to reduce dust.    Allergens in the surroundings reduce the patient’s ability to access oxygen while breathing.    
Positioning the patient in a semi Fowler’s position with the head of the bed at 45 degrees when lying down, as permitted.  The upright or semi Fowler’s position allows for higher thoracic potential, total diaphragm descent, and increased lung expansion, which prevents the abdominal components from contracting.  
Keep an eye out for changes in blood pressure and heart rate.  With preliminary hypoxia and hypervolemia, blood pressure, heart rate, and breathing rate rise. Nevertheless, blood pressure and heart rate drop, and dysrhythmias can happen when both circumstances become drastic.    
Determine the patient’s hydration level.    In patients with heart failure, excessive hydration may impair gas exchange. In patients with pneumonia and COPD, however, dehydration may interfere with the ability to clear secretions.  

Nursing References

Ackley, 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.

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