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Polish up on client care 51

increased partial pressure of arterial carbon dioxide; and possible decreased Hb and HCT (if the client is bleeding). Gastroscopy, aspiration of gastric contents through a nasogastric tube, and X-rays iden-tify internal bleeding sites. ABG analysis reveals metabolic acidosis.

NURSING DIAGNOSES Ineffective tissue perfusion: Cardiopulmonary, renal, cerebral, GI Decreased cardiac output Deficient fluid volume

TREATMENT Blood and fluid replacement Control of bleeding

INTERVENTIONS AND RATIONALESManagement of hypovolemic shock necessi-tates prompt, aggressive supportive measures and careful assessment and monitoring of vital signs. Follow these priorities: Check for a patent airway and adequate circulation. If blood pressure and heart rate are absent, start CPR to prevent irreversible organ damage and death. Record blood pressure, pulse rate, peripheral pulses, respiratory rate, and pulse oximetry every 15 minutes and monitor the ECG continuously. A systolic blood pressure lower than 80 mm Hg usually results in inad-equate coronary artery blood flow, cardiac ischemia, arrhythmias, and further compli-cations of low cardiac output. When blood pressure drops below 80 mm Hg, increase the oxygen flow rate and notify the physi-cian immediately. A progressive drop in blood pressure accompanied by a thready pulse gen-erally signals inadequate cardiac output from reduced intravascular volume. Insert large-bore (14G) I.V. catheters and infuse normal saline or lactated Ringers solution and appropriate blood products, as indicated, to correct fluid volume deficit. Insert an indwelling urinary catheter to measure hourly urine output. If output is less than 30 ml/hour in adults, increase the fluid infusion rate but watch for signs of fluid over-load, such as an increase in PAWP. Notify the physician if urine output doesnt improve. An osmotic diuretic such as mannitol (Osmitrol)

Beginning a smoking cessation program, if appropriate Reducing alcohol intake to moderate levels Following a low-cholesterol, low-sodium diet Following a program of regular exercise Losing weight, if appropriate Contacting the American Heart Association

Hypovolemic shock

In hypovolemic shock, reduced intravascular blood volume causes circulatory dysfunction and inadequate tissue perfusion. Without sufficient blood or fluid replacement, hypovo-le mic shock syndrome may lead to irrevers-ible cerebral and renal damage, cardiac arrest and, ultimately, death.

Hypovolemic shock requires early recog-nition of signs and symptoms and prompt, aggressive treatment to improve the prognosis.

CAUSES Acute blood loss (approximately one-fifth of total volume) Acute pancreatitis Dehydration from excessive perspiration Diabetes insipidus Diuresis Inadequate fluid intake Intestinal obstruction Peritonitis Severe diarrhea or protracted vomiting

ASSESSMENT FINDINGS Cold, pale, clammy skin Decreased sensorium Hypotension with narrowing pulse pressure Rapid, shallow respirations Reduced urine output (less than 25 ml/hour) Tachycardia

DIAGNOSTIC TEST RESULTS Blood tests show elevated potassium, serum lactate, and BUN levels; increased urine specific gravity (greater than 1.020) and urine osmolality; decreased blood pH; decreased partial pressure of arterial oxygen,

I better back up and study assessment

findings again. Early recognition of signs and symptoms of hypovolemic shock are necessary to

prevent irreversible damage.

313419NCLEX-RN_Chap03.indd 51313419NCLEX-RN_Chap03.indd 51 4/8/2010 7:01:47 PM4/8/2010 7:01:47 PM

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