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12 Cards in this Set

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Description of Hypovolemic Shock
Occurs when to little circulating bloos volume causes a MAP decrease so that the body's total need for oxygen is not met
Causes
Body Fluid depletion related to Hemmorrhage AEB (Trauma, Gastrointestinal ulcer, Surgery, Inadequate clotting...examples of inadequate clotting is hemophilla, liver disease, malnutrition, bone marrow supression, cancer Anticoagulation therapy)
Dehydration AEB Vomiting, diarrhea, heavy diaphoresis, diuretic therapy, NG suction, Diabetes insipidus, hyperglycemia
Common Characteristics
Pallor, tachycardia, hypotension, cool skin, altered LOC
Assessment (History)
A.Ask Pt. about recent illness, trauma, procedures or chronic health problems (may include GI ulcers, general surgery, hemophillia, liver disorder, prolonged vomiting/diarrhea.
B.Ask about use of drugs, such as aspirin, diurectics and antacids
C.Ask about fulid intake and output during last 24 hours (this is important reduced urine output is first stages of shock, even if intake is normal)
D.Assess for signs of hemorrhage in the gums, wounds, sites of dressings, drains, and vascular accesses,under the pt. Observes for welling or skin discoloration that may indicate internal hemorrhage.
Physical Assessment(clinical manifestations)
A.Assess the central and peripheral pulses for rate and quality(tachycardia). As shock progresses peripheral pulse may be absence
B. Assess BP(hypotension) As shock progresses systolic pressure and cardiac output decreases. If shock progresses futher without interventions diastolic will decrease too.
C. Assess Oxygen SAT. 90 to 95% occurs with nonprogressive shock. 75 to 80% occur with progressive shock. Under 70% may be refractory shock.
D. Assess Skin for temp, color, degree of moisture, and capillary refill(Pallor, cool skin,sluggish refill)
E. Assess Respiratory changes for rate depth and ease, auscultate lungs for abnormal breath sounds(tachypnea)As shock progresses depth increases also
F. Assess Renal/Urinary Changes. Assess urine for volume, color, specific gravity and presence of blood or proteins. Measure output at least every hour.As shock progresses and is sever urine out put is sometimes absent
G. Assess LOC and orientation to person, place and time.(Inital and progressive stages clients may be restless or agitated and may be anxious or have a feeling of impending doom)(as hypoxia progressess confusion and lethargy occurs maybe even loss of consciousness)
H. Assess for muscle weakness
Psychosocial Assessment
Changes in mental status and behavior may be early signs of shock. Asses LOC and orientation to place, person, and time.
Avoid ?'s that are answered with a yes or no
LAboratory Assessment
Ph decreases
PaO2 decreases
PaCO2 increases
K+ increases
Hematocrit and hemoglobin level decrease if caused by hemorrhage and increase if caused by dehydration
Nursing DX
Anxiety related to potential for death
Deficient fluid volume related to active fluid volume loss
Deceased cardiac output related to hypovolemia
Ineffective tissue perfusion (general) related to hypovolemia
Disturbed thought processes related to decreased cerebral perfusion
Best practice for the client with hypovolemic shock
-Ensure patent airway
-start an IV or KVO
-Administer Oxygen
-Elevate feet, keep head flat or 30 degree angle
-Examine client for bleeding, if present apply pressure
-Administer MEDS as prescribed
-Increase IV fluid rate
-DO NOT LEAVE CLIENT
Drug therapy
generic name
(trade name)
A.Vasoconstrictors
1.Dopamine hydrochloride(Intropin, Revimine)
2. Epinephrine
(Adrenalin)
3.Norepinephrine
(Levophed)
4.Phenylephrine
(Neo-synephrine)
B. Agents enhancing Contractility
1. Milrinone
(Primacor)
2. Atropine Sulfate
3.Doburamine hydrochloride
(Dobutrex)
C. Agents Enhancing Myocardial Perfusion
1.Sodium nitroprusside
(Nitropress, Nipride)
Other Interventions
A.Giving (Colloid Fluids) blood products and blood are given for shock when resulted by blood loss. These restore osmotic pressure and fluid volume
B. Giving Crystalloid Fluids such as ringers lactate and NS, these help maintain adequate fluid and electrolyte balance
c. Oxygen Therapy
d. Surgical repair may be needed
Monitoring
Pulse, BP, Pulse Pressure, Central Venous Pressure, Respiratory Rate, Skin and mucosal color, Oxygen SAT.