HYPOVOLEMIC SHOCK - Is a decreased venous return to the heart CLASSIFICATIONS OF HYPOVOLEMIC SHOCK Non-Hemorrhagic hypovolemic shock (fluid loss)

) a. Causes of water and electrolyte loses * Vomiting, Refractory gastroenteritis, * Diuretics *Osmotic diuresis (diabetic ketoacidosis, hyperosmolar nonketonic coma) * Salt wasting nephropathies. * Hypoaldosteronism *Excessive sweating *Hyperventilation b. Causes of plasma losses (third spacing) Bowel obstruction. Peritonitis. Ileostomy losses Pancreatitis Ascites Extensive burns: destruction of the epidermis produces massive evaporative losses massive edema formation Trauma/ Hemorrhagic hypovolemic shock a. Blood loss from penetrating injuries : Haemothorax Intraperitoneal or retroperitoneal bleeding b. Upper and lower severe gastrointestinal tract bleeding disorders from: Oesophageal varices, peptic ulcers, aortointestinal fistulas Haemorrhagic pancreatitis c. Pregnancy disorders: Ruptured ectopic pregnancy, b. placenta previa, and abruption placenta

Stages of hypovolemic shock Stage 1 - Up to 15% blood volume loss (750 mL) - Compensated by constriction of vascular bed - Blood pressure maintained - Normal respiratory rate - Pallor of the skin - Normal mental status to slight anxiety - Normal capillary refill - Normal urine output

Stage 2 1530% blood volume loss (7501500 Ml) Cardiac output cannot be maintained by arterial constriction Tachycardia >100bpm Increased respiratory rate Blood pressure maintained Increased diastolic pressure Narrow pulse pressure Sweating from sympathetic stimulation Mildly anxious/Restless Delayed capillary refill Urine output of 20-30 milliliters/hour Stage 3 3040% blood volume loss (15002000 mL) Systolic BP falls to 100mmHg or less Classic signs of hypovolemic shock Marked tachycardia >120 bpm Marked tachypnea >30 bpm Alteration in mental status Sweating with cool, pale skin Delayed capillary refill Urine output of approximately 20 milliliters/hour Stage 4 Loss greater than 40% (>2000 mL) Extreme tachycardia (>140) with weak pulse Pronounced tachypnea Significantly decreased systolic blood pressure of 70 mmHg or less Decreased level of consciousness Skin is sweaty, cool, and extremely pale (moribund) Absent capillary refill Negligible urine output

SIGNS AND SYMPTOMS Clinical symptoms may not be present until 1020% of total whole-blood volume is lost. Assessment findings: 1. Systolic blood pressure less than 90 mm Hg or 30 mm Hg less than baseline values 2. Rapid weak pulse 3. Dyspnea 4. Tachypnea 5. Cool, clammy skin 6. Pallor 7. Extreme thirst 8. Irritability 9. Urine output less than 30mL/hr

COMPLICATIONS stroke, heart attack liver failure kidney failure gangrene of an extremity adult respiratory distress syndrome Sepsis disseminated intravascular coagulation multiple organ dysfunction syndrome ASSESSMENT Obtain History - recent alterations in fluid volume intake or excessive loss - attempt to identify a family member or significant other to discuss the patient's psychosocial history In addition, obtain a subjective history of: 1. thirst, 2. lethargy, and 3. decreased urinary output Palpate the patient's peripheral pulses and note signs of decreased blood flow and inadequate tissue perfusion Four areas are considered to be life threatening: (1) chest (auscultate for decreased breath sounds), (2) abdomen (examine for tenderness or distention), (3) thighs (check for deformities and bleeding into soft tissues) (4) external bleeding

DIAGNOSTICS a. CBC b. ABG c. BUN-CREA d. Coagulation studies e. Cross-matching f. Serum Electrolyte Levels (Na, K, Cl, HCO3, BUN, Creatinine, Glucose Levels) g. Prothrombin time h. Activated Partial Thromboplastin Time i. Urinalysis - in patients with trauma j. Pregnancy Test - should be performed in all female patients of childbearing age

Imaging Studies Ultrasonographic Examination - if anabdominal aortic aneurysm is suspected - if the patient is pregnant and in shock, surgical consultation and the consideration of bedside pelvic ultrasonography should be immediately performed. Upright chest radiograph -if a perforated ulcer or Boerhaave syndrome is a possibility Endoscopy -can be performed (usually after the patient has been admitted) to further delineate the source of bleeding CT scan GENERAL TREATMENT Keep the person comfortable and warm Have the person lie flat with the feet lifted about 12 inches. Do not give fluids by mouth. If person is having an allergic reaction, treat the allergic reaction. If the person must be carried, try to keep him or her flat, with the head down and feet lifted. Stabilize the head and neck before moving a person with a suspected spinal injury. The patient's airway should be assessed immediately upon arrival and stabilized if necessary. An intravenous (IV) line will be put into the person's arm to allow blood or blood products to be given. Medicines such as dopamine, dobutamine, epinephrine, and norepinephrine may be needed MEDICAL MANAGEMENT If bleeding is present, STOP the bleeding by applying pressure on the site. If it is non-hemorrhagic, medications to treat the underlying cause are given. Fluid replacement (also known as Fluid Resuscitation). NURSING MANAGEMENT 1. Assessment Bleeding: amount of blood loss, bleeding site Jugular vein distention, jugular vein pressure Signs of Cardio-pulmonary distress Lung sounds 2. Monitor the following: Vital signs Input and output Hgb and Hct levels Arterial blood gas Hemodynamic pressure

 Temperature 3. Anticipate the need for blood transfusions. 4. Monitor fluid replacements . 5. Position in Modified Trendelenburg. 6. Administer oxygen per nasal cannula or mask. 7. Promote safety and comfort. FLUID REPLACEMENT COMPLICATIONS: cardiovascular overload difficulty of breathing pulmonary edema hypothermia (because of rapid fluid resuscitation) jugular vein distention

Saint Louis University Baguio City SCHOOL OF NURSING

HYPOVOLEMIC SHOCK

Submitted by: Baquiran, Jimmy Sevilla, Allan Advincula, Donalyn Fabros, Joanna Hidalgo, Dana Sophia Jose, Carina Jean Lee, Christine Joy Molina, Ma. Klaudyn Cletz Narciso, Queenie Mae Pilipina, Jasmine Serafica, Arra Cristine Tagayo, Rhozen Ely Vargas, Karole Cay Submitted to: Mrs. Julie Ann Uy Instructor