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HYPOVOLEMIC SHOCK...NURSING CARE PLAN
Pathophysiology
Hypovolemic shock is a loss of blood volume leading to decreased oxygenation of vital organs. The body’s compensatory mechanisms fail and organs begin to shut down.
Etiology
Any condition causing loss of circulating blood or plasma volume. Hemorrhage from any large source. Traumatic injuries. Burns (plasma loss due to capillary permeability). Prolonged vomiting or diarrhea.
Desired Outcome
The goal is to restore circulating blood volume, preserve hemodynamics, and prevent any damage to vital organs.
Hypovolemic Shock Nursing Care Plan
Subjective Data:
Weakness
Anxiety or restlessness
Report of vomiting or diarrhea
Report of rectal or vaginal bleeding
Objective Data:
Measured fluid loss greater than 1500 mL
Hemorrhage or Burn
↑ HR
↑ RR
↓ BP
↓ CVP
↓ CO
↑ SVR
↓ LOC
↓ Urine output
Cool, pale, clammy skin
Nursing Interventions and Rationales
Assess for Risk
bleeding risk
burns
GI/GU losses
Causes of shock include:
Blood loss from:
Traumatic injuries
Internal bleeding, such as a GI bleed or surgical complication
Postpartum hemorrhage
Fluid loss from:
Burns
Diarrhea
Vomiting
Nurses should assess their patient for the risk of developing hypovolemic shock. The patient may have lost some fluid already, or maybe they’re at risk for bleeding. Either way, the more aware the nurse is of the risk, the more likely it can be prevented or caught early.
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