Hypovolemic Shock nursing Care Plan: Nursing Assessment, Diagnosis, and Interventions

Posted on by Soumya Ranjan Parida
Hypovolemic Shock: Comprehensive Nursing Care Plans | Evidence-Based Interventions

Hypovolemic Shock: Comprehensive Nursing Care Plans

Evidence-based interventions for nursing students

Table of Contents

Introduction Overview of Hypovolemic Shock 1. Decreased Cardiac Output 2. Deficient Fluid Volume 3. Ineffective Tissue Perfusion 4. Anxiety 5. Impaired Gas Exchange 6. Risk for Infection 7. Hypothermia 8. Acute Pain 9. Ineffective Peripheral Tissue Perfusion 10. Decreased Intracranial Adaptive Capacity 11. Risk for Electrolyte Imbalance 12. Risk for Impaired Renal Function 13. Deficient Knowledge 14. Disturbed Body Image 15. Powerlessness References

Introduction

Hypovolemic shock is a life-threatening condition that occurs when there is a significant decrease in intravascular blood volume, leading to inadequate tissue perfusion and cellular oxygen deprivation. As nursing professionals, recognizing the early signs of hypovolemic shock and implementing appropriate nursing interventions is crucial for improving patient outcomes.Hypovolemic Shock nursing Care Plan

This comprehensive guide provides 15 evidence-based nursing care plans specifically designed for managing patients experiencing hypovolemic shock. Each care plan includes NANDA nursing diagnoses, assessment parameters, expected outcomes, interventions with rationales, and evaluation criteria to guide nursing students in delivering optimal care.

Key Learning Points

  • Identifying early signs and symptoms of hypovolemic shock
  • Prioritizing nursing interventions based on patient assessment
  • Implementing evidence-based practice in emergency situations
  • Documenting and evaluating patient responses to interventions
  • Collaborating with the interdisciplinary healthcare team

Overview of Hypovolemic Shock

Hypovolemic shock results from a significant loss of blood, plasma, or fluids, leading to inadequate tissue perfusion and cellular hypoxia. This critical condition requires prompt recognition and intervention to prevent irreversible organ damage and death.

Common Causes

  • External hemorrhage (trauma, surgery)
  • Internal hemorrhage (GI bleeding, ruptured aneurysm)
  • Severe dehydration (vomiting, diarrhea, burns)
  • Excessive diuresis
  • Third-space fluid shifts (pancreatitis, burns)

Clinical Manifestations

  • Tachycardia, hypotension
  • Decreased urine output
  • Altered mental status
  • Cool, pale, clammy skin
  • Weak, thready pulse
  • Delayed capillary refill (>3 seconds)

Stages of Hypovolemic Shock

Stage Blood Volume Loss Clinical Presentation
Class I Up to 15% Minimal tachycardia, normal blood pressure, anxiety
Class II 15-30% Tachycardia, decreased pulse pressure, mild hypotension, restlessness
Class III 30-40% Marked tachycardia, hypotension, oliguria, altered mental status
Class IV >40% Extreme tachycardia, severe hypotension, anuria, lethargy/unconsciousness

Critical Nursing Alert

Remember that elderly patients, pregnant women, and those on beta-blockers may not exhibit the typical compensatory tachycardia seen in hypovolemic shock. Assessment should focus on multiple parameters rather than a single vital sign.

Nursing Care Plan 1: Decreased Cardiac Output

NANDA Diagnosis: Decreased Cardiac Output related to reduced preload secondary to hypovolemia as evidenced by hypotension, tachycardia, and decreased peripheral pulses

Assessment Data:

  • Vital signs: BP <90/60 mmHg, HR >100 bpm
  • Weak, thready peripheral pulses
  • Cool, pale extremities
  • Delayed capillary refill (>3 seconds)
  • Decreased central venous pressure (CVP)
  • Decreased cardiac output/index
  • Altered level of consciousness

Expected Outcomes:

  • Patient will maintain adequate cardiac output as evidenced by:
    • BP within patient’s normal range or >90/60 mmHg
    • Heart rate 60-100 bpm
    • Strong peripheral pulses
    • Capillary refill <3 seconds
    • Warm, dry skin with good color
    • Alert and oriented mental status
    • Urine output >30 ml/hr

Nursing Interventions with Rationales:

Nursing Interventions Rationale
Monitor vital signs, including BP, HR, RR, and oxygen saturation q15min or continuously during acute phase. Provides early detection of deterioration or improvement in hemodynamic status and allows for timely intervention.
Assess peripheral pulses, capillary refill, skin color/temperature, and mental status q15-30min. These are indicators of tissue perfusion and can reveal early signs of decompensation before vital sign changes occur.
Administer fluid resuscitation as prescribed (crystalloids, colloids, or blood products). Restores intravascular volume to improve preload and cardiac output. Type and rate of fluid should be based on cause of hypovolemia and patient’s clinical status.
Position patient supine with legs elevated 20-30 degrees (modified Trendelenburg) unless contraindicated. Augments venous return to the heart, improving preload and cardiac output. Full Trendelenburg is no longer recommended due to potential respiratory compromise.
Monitor response to fluid resuscitation, including BP, HR, CVP, pulmonary artery pressures, and cardiac output if available. Evaluates effectiveness of volume replacement therapy and guides further interventions. Excessive fluid may lead to pulmonary edema or heart failure.
Monitor urine output hourly (goal >0.5ml/kg/hr). Kidney perfusion is sensitive to reduced cardiac output; adequate urine output indicates improving renal perfusion.
Administer vasopressors and/or inotropic medications as prescribed if fluid resuscitation alone is insufficient. Improves cardiac contractility and vascular tone when hypovolemia is corrected but shock persists.
Continuously monitor cardiac rhythm. Hypovolemia can trigger dysrhythmias from coronary hypoperfusion or electrolyte imbalances.

Evaluation:

Evaluate the patient’s response to interventions by assessing:

  • Normalization of vital signs
  • Improved peripheral perfusion (warm extremities, strong pulses, normal capillary refill)
  • Enhanced mental status
  • Adequate urine output
  • Balanced fluid input and output
  • Improved hemodynamic parameters (if monitored)

Nursing Care Plan 2: Deficient Fluid Volume

NANDA Diagnosis: Deficient Fluid Volume related to active fluid loss or inadequate fluid intake as evidenced by hypotension, tachycardia, decreased skin turgor, and dry mucous membranes

Assessment Data:

  • Vital signs: BP <90/60 mmHg, HR >100 bpm
  • Decreased skin turgor
  • Dry mucous membranes
  • Weight loss >5% from baseline
  • Concentrated urine (specific gravity >1.030)
  • Decreased urine output (<30 ml/hr)
  • Sunken eyeballs
  • Elevated hematocrit (hemoconcentration)
  • Thirst

Expected Outcomes:

  • Patient will achieve fluid balance as evidenced by:
    • Stable vital signs within patient’s normal range
    • Moist mucous membranes
    • Improved skin turgor
    • Urine output >0.5ml/kg/hr
    • Urine specific gravity 1.005-1.025
    • Balanced fluid input and output
    • Stable weight
    • Normal electrolyte levels

Nursing Interventions with Rationales:

Nursing Interventions Rationale
Establish and maintain IV access with large-bore catheters (16-18 gauge). Large-bore catheters allow for rapid fluid administration during resuscitation.
Administer prescribed IV fluids at appropriate rate (e.g., bolus vs. maintenance). Restores intravascular volume; rate depends on severity of deficit and patient’s cardiac and renal status.
Monitor fluid intake and output strictly, including all sources (IV, oral, drainage, wounds, insensible). Accurate measurement allows assessment of fluid balance status and response to therapy.
Weigh patient daily at same time, using same scale and clothing conditions. Body weight is a reliable indicator of fluid status; 1 kg weight change represents approximately 1 liter of fluid.
Assess skin turgor, mucous membranes, and thirst q4h. These are clinical indicators of hydration status that can be easily evaluated at the bedside.
Monitor laboratory values: BUN/creatinine ratio, hematocrit, electrolytes, and osmolality. Elevated BUN/creatinine ratio and hematocrit indicate hemoconcentration; electrolyte imbalances often accompany fluid deficits.
If source of fluid loss is identifiable (e.g., GI bleeding, external hemorrhage), take measures to control the source. Controlling the source of fluid loss is essential for effective volume resuscitation and prevention of continued depletion.
Insert urinary catheter to monitor output accurately. Allows for precise measurement of urine output, an important indicator of renal perfusion and fluid status.
Administer blood products as prescribed for hemorrhagic shock. Restores oxygen-carrying capacity and intravascular volume in cases of significant blood loss.

Evaluation:

Evaluate the patient’s response to interventions by assessing:

  • Normalization of vital signs
  • Improved skin turgor and mucous membrane moisture
  • Balanced I&O
  • Stable weight
  • Normal urine output and specific gravity
  • Normalized laboratory values

Nursing Care Plan 3: Ineffective Tissue Perfusion

NANDA Diagnosis: Ineffective Tissue Perfusion (peripheral, cerebral, renal, gastrointestinal) related to decreased blood flow secondary to hypovolemia as evidenced by altered vital signs, decreased peripheral pulses, and altered mental status

Assessment Data:

  • Diminished or absent peripheral pulses
  • Cool, pale, or mottled extremities
  • Delayed capillary refill (>3 seconds)
  • Altered mental status (confusion, restlessness, lethargy)
  • Decreased urine output (<30 ml/hr)
  • Elevated lactate levels (>2 mmol/L)
  • Metabolic acidosis (decreased pH, decreased bicarbonate)
  • Elevated BUN and creatinine
  • Abdominal pain, decreased bowel sounds (GI hypoperfusion)

Expected Outcomes:

  • Patient will demonstrate adequate tissue perfusion as evidenced by:
    • Strong peripheral pulses
    • Warm extremities with normal color
    • Capillary refill <3 seconds
    • Alert and oriented mental status
    • Urine output >0.5ml/kg/hr
    • Normal lactate levels (<2 mmol/L)
    • Normalized acid-base balance
    • Normal BUN and creatinine levels
    • Normal bowel sounds

Nursing Interventions with Rationales:

Nursing Interventions Rationale
Assess peripheral pulses, capillary refill, skin color, and temperature q15-30min during acute phase. Early detection of changes in peripheral perfusion allows for prompt intervention before tissue damage occurs.
Assess neurological status including level of consciousness, orientation, and pupillary response q1h. Changes in neurological status may indicate cerebral hypoperfusion requiring immediate intervention.
Monitor urine output hourly, noting color, clarity, and specific gravity. Urine output is a sensitive indicator of renal perfusion; oliguria (<0.5ml/kg/hr) suggests inadequate renal blood flow.
Assess abdominal status: pain, distention, bowel sounds q4h. Splanchnic hypoperfusion can lead to ileus, ischemic bowel, and bacterial translocation.
Monitor arterial blood gases, lactate, and base deficit q4-6h. Metabolic acidosis and elevated lactate indicate ongoing tissue hypoperfusion and anaerobic metabolism.
Administer oxygen as prescribed to maintain SpO2 >94%. Optimizes oxygen delivery to tissues, especially important when blood flow is compromised.
Implement fluid resuscitation per protocol, guided by clinical parameters and, if available, dynamic measures of fluid responsiveness. Restores intravascular volume to improve tissue perfusion. Dynamic measures (e.g., pulse pressure variation) may guide fluid administration better than static parameters.
Reposition patient q2h if hemodynamically stable; avoid pressure on areas with compromised circulation. Prevents pressure injuries in areas with compromised perfusion that are more susceptible to tissue breakdown.
Administer vasopressors as prescribed if fluid resuscitation alone is insufficient. Maintains perfusion pressure to vital organs when hypovolemia is corrected but shock persists.

Evaluation:

Evaluate the patient’s response to interventions by assessing:

  • Improvement in peripheral pulses and skin temperature/color
  • Return to baseline mental status
  • Adequate urine output
  • Normalization of laboratory values (lactate, base deficit)
  • Resolution of metabolic acidosis
  • Normal bowel sounds and abdominal assessment

Nursing Care Plan 4: Anxiety

NANDA Diagnosis: Anxiety related to situational crisis and threat to self-concept as evidenced by expressed concerns, restlessness, and increased tension

Assessment Data:

  • Verbalized fear and worry
  • Restlessness, agitation
  • Increased tension
  • Focus on self
  • Increased heart rate and blood pressure (when not related to hypovolemia)
  • Diaphoresis
  • Trembling, shakiness
  • Facial tension
  • Increased respiratory rate

Expected Outcomes:

  • Patient will demonstrate reduced anxiety as evidenced by:
    • Verbalization of feeling more calm and in control
    • Decreased physical manifestations of anxiety
    • Use of effective coping strategies
    • Improved ability to rest
    • Participation in treatment decisions when appropriate

Nursing Interventions with Rationales:

Nursing Interventions Rationale
Establish a calm, quiet environment when possible; minimize unnecessary noise and intrusions. Environmental stimuli can increase anxiety, particularly in acute stress situations.
Use a calm, reassuring approach; remain with patient during periods of increased anxiety. Therapeutic presence can provide security and comfort; anxiety is often heightened when patients feel alone.
Explain all procedures, treatments, and expected sensations in simple, concise language before proceeding. Knowledge and preparation reduce fear of the unknown, giving patients some sense of control.
Acknowledge the patient’s feelings and concerns; validate their emotional experience. Validation helps patients feel understood and supports their emotional processing.
Provide factual information about the patient’s condition, treatment, and prognosis at a level they can understand. Accurate information helps correct misconceptions that may contribute to anxiety.
Encourage the expression of feelings and concerns. Verbalization of fears can help reduce anxiety and provides insight into specific concerns that can be addressed.
Teach simple relaxation techniques (deep breathing, visualization) appropriate to patient’s condition. These techniques activate the parasympathetic nervous system, helping reduce physiological stress responses.
Include family/significant others in care and explanations as appropriate. Family support can reduce patient anxiety; informed family members can also provide better emotional support.
Administer anxiolytic medications as prescribed, monitoring for effectiveness and side effects. Pharmacological intervention may be necessary when anxiety is severe or when physiological parameters are being affected.

Evaluation:

Evaluate the patient’s response to interventions by assessing:

  • Patient’s subjective report of anxiety level
  • Observable signs of anxiety (restlessness, facial tension, etc.)
  • Use of coping strategies
  • Ability to rest and sleep
  • Engagement in care decisions
  • Vital signs not affected by anxiety

Nursing Care Plan 5: Impaired Gas Exchange

NANDA Diagnosis: Impaired Gas Exchange related to ventilation-perfusion mismatch secondary to decreased cardiac output as evidenced by hypoxemia, tachypnea, and dyspnea

Assessment Data:

  • Decreased oxygen saturation (<94% on room air)
  • Decreased PaO2 (<80 mmHg)
  • Increased respiratory rate (>20 breaths/min)
  • Dyspnea, shortness of breath
  • Use of accessory muscles for breathing
  • Abnormal breath sounds
  • Restlessness, irritability
  • Cyanosis (late sign)
  • Metabolic acidosis (decreased pH, decreased HCO3)

Expected Outcomes:

  • Patient will demonstrate adequate gas exchange as evidenced by:
    • Oxygen saturation >94% (or within patient’s baseline range)
    • PaO2 >80 mmHg
    • Respiratory rate 12-20 breaths/min
    • Absence of dyspnea
    • Clear breath sounds
    • Normal skin color
    • Normalized acid-base balance

Nursing Interventions with Rationales:

Nursing Interventions Rationale
Monitor respiratory status: rate, depth, effort, use of accessory muscles, breath sounds q1-2h or more frequently if unstable. Early detection of respiratory compromise allows for prompt intervention before significant hypoxemia develops.
Continuously monitor oxygen saturation via pulse oximetry; obtain arterial blood gases as ordered. Provides objective data on oxygenation status and acid-base balance. ABGs provide more comprehensive information than pulse oximetry alone.
Administer oxygen therapy as prescribed, titrating to maintain SpO2 >94% (or as ordered). Supplemental oxygen improves alveolar oxygen content, enhancing diffusion across the alveolar-capillary membrane.
Position patient to optimize ventilation-perfusion matching (e.g., semi-Fowler’s position if tolerated hemodynamically). Upright positioning maximizes lung expansion and decreases work of breathing; however, position must be balanced with hemodynamic stability in hypovolemic shock.
Encourage deep breathing exercises when patient is stable enough. Promotes alveolar expansion, prevents atelectasis, and improves ventilation.
Suction airway as needed, based on assessment. Removes secretions that may obstruct airways and impair gas exchange.
Collaborate with respiratory therapy for advanced respiratory interventions as needed (CPAP, BiPAP, intubation). Progressive respiratory support may be required if oxygenation cannot be maintained with basic interventions.
Address the underlying cause by restoring circulating volume and cardiac output. Improving perfusion is essential to correct ventilation-perfusion mismatch in hypovolemic shock.
Monitor hemoglobin and hematocrit; administer blood products as prescribed. Adequate hemoglobin is necessary for optimal oxygen-carrying capacity.

Evaluation:

Evaluate the patient’s response to interventions by assessing:

  • Improvement in oxygen saturation and PaO2
  • Normalization of respiratory rate and pattern
  • Resolution of dyspnea and use of accessory muscles
  • Clear breath sounds
  • Normal skin color
  • Normalized ABGs and acid-base balance

Nursing Care Plan 6: Risk for Infection

NANDA Diagnosis: Risk for Infection related to invasive procedures, inadequate primary defenses, and decreased immune function secondary to hypovolemic shock

Risk Factors:

  • Multiple invasive procedures (IV lines, arterial lines, central lines, urinary catheters)
  • Compromised skin integrity (surgical wounds, trauma sites)
  • Decreased tissue perfusion and oxygenation
  • Immunosuppression due to stress response and compromised perfusion
  • Blood transfusions (immunomodulatory effects)
  • Exposure to nosocomial pathogens in healthcare setting
  • Malnutrition secondary to critical illness

Expected Outcomes:

  • Patient will remain free from infection as evidenced by:
    • Normal temperature (36.5-37.5°C)
    • Normal white blood cell count (4,500-11,000/μL)
    • No signs of infection at invasive device sites
    • Negative cultures (if obtained)
    • No purulent drainage from wounds
    • Clear lung sounds without new infiltrates on imaging
    • Clear urine without signs of infection

Nursing Interventions with Rationales:

Nursing Interventions Rationale
Practice and maintain aseptic technique for all invasive procedures, including IV insertion, dressing changes, and catheter care. Aseptic technique is the cornerstone of infection prevention, reducing microbial contamination during procedures.
Monitor all invasive sites q4h for signs of infection: redness, swelling, warmth, pain, and purulent drainage. Early identification of localized infection can prevent systemic spread and sepsis.
Change IV tubing and administration sets according to facility protocol (typically q96h for continuous infusions, q24h for blood products). Regular changes of IV equipment according to evidence-based guidelines reduces risk of catheter-related infections.
Maintain closed urinary drainage system; keep collection bag below level of bladder. Prevents reflux of urine and bacterial migration up the catheter into the bladder.
Perform hand hygiene before and after all patient contact and encourage visitors to do the same. Hand hygiene is the single most effective measure to prevent healthcare-associated infections.
Monitor temperature q4h and report elevations >38.3°C or per facility protocol. Fever is often the first sign of infection in critically ill patients, though some may present with hypothermia.
Monitor WBC count and differential; report significant changes. Leukocytosis or leukopenia may indicate developing infection; left shift (increased bands) suggests acute bacterial infection.
Implement early progressive mobility as patient condition allows. Immobility increases risk of pneumonia and pressure injuries; early mobilization reduces these risks.
Provide meticulous oral care q4h for intubated patients, q8h for non-intubated patients. Reduces oral bacterial colonization that can lead to ventilator-associated pneumonia or aspiration pneumonia.
Administer prophylactic antibiotics as prescribed. May be indicated in certain traumatic injuries, surgical procedures, or high-risk situations.
Remove invasive devices as soon as no longer clinically indicated. Every day with an invasive device increases infection risk; daily evaluation of necessity is recommended.

Evaluation:

Evaluate the patient’s status by assessing:

  • Temperature trends
  • WBC count and differential
  • Appearance of all invasive sites
  • Wound assessment
  • Respiratory status and sputum characteristics
  • Urine appearance and urinalysis results
  • Culture results (if obtained)
  • Presence of new or changing symptoms that could indicate infection

Nursing Care Plan 7: Hypothermia

NANDA Diagnosis: Hypothermia related to exposure to cool environment, inadequate clothing/covering, decreased metabolic rate, and shock state as evidenced by reduced body temperature, shivering, and cool skin

Assessment Data:

  • Body temperature below 36°C (96.8°F)
  • Shivering (may be absent in severe hypothermia)
  • Cool skin to touch
  • Pallor or cyanotic skin
  • Decreased capillary refill
  • Bradycardia (in moderate to severe hypothermia)
  • Decreased respiratory rate
  • Impaired mental status (confusion, lethargy)
  • Potential for dysrhythmias (especially atrial fibrillation)

Expected Outcomes:

  • Patient will maintain normal body temperature (36.5-37.5°C) as evidenced by:
    • Temperature within normal range
    • Absence of shivering
    • Warm skin
    • Normal skin color
    • Stable cardiac rhythm
    • Normalization of vital signs

Nursing Interventions with Rationales:

Nursing Interventions Rationale
Monitor core body temperature continuously or q1h using appropriate method (rectal, esophageal, or bladder temperature monitoring preferred in severe hypothermia). Core temperature provides more accurate assessment than peripheral measurements in hypothermia. Continuous monitoring allows for rapid detection of changes.
Remove wet clothing and cover patient with warm blankets. Wet clothing accelerates heat loss through evaporation and conduction.
Apply forced-air warming blanket set at appropriate temperature. Forced-air warming is effective for passive rewarming in mild hypothermia and as an adjunct in moderate hypothermia.
Warm IV fluids to 37-40°C before administration. Cold fluids can significantly lower core body temperature; warming IV fluids prevents further heat loss and can assist in rewarming.
Maintain ambient room temperature between 24-27°C (75-80°F). Warm environment reduces heat loss through radiation and convection.
Monitor cardiac rhythm continuously; be alert for J-waves (Osborn waves) and dysrhythmias. Hypothermia predisposes to various dysrhythmias, particularly atrial fibrillation and ventricular dysrhythmias. J-waves may appear on ECG at temperatures below 32°C.
Handle patient gently during care activities. Rough handling may trigger dysrhythmias in hypothermic patients due to increased myocardial irritability.
Monitor blood glucose levels as hypothermia may mask hypoglycemia. Hypothermia can impair pancreatic insulin release and peripheral glucose utilization, potentially masking hypoglycemia.
Monitor for coagulation abnormalities; hypothermia impairs clotting function. Hypothermia causes platelet dysfunction and inhibits coagulation enzyme function, worsening hemorrhage risk in hypovolemic shock.
For moderate to severe hypothermia, implement active core rewarming techniques as prescribed (warmed humidified oxygen, body cavity lavage, extracorporeal blood warming). Active core rewarming is indicated for temperatures below 32°C or in patients with cardiovascular instability. Rate of rewarming should be controlled to avoid complications.

Rewarming Alert

Be vigilant for “rewarming shock” during active rewarming procedures. As peripheral vasodilation occurs during rewarming, relative hypovolemia can be exacerbated, requiring additional fluid resuscitation.

Evaluation:

Evaluate the patient’s response to interventions by assessing:

  • Core body temperature trending toward normal range
  • Resolution of shivering
  • Improvement in skin temperature and color
  • Stabilization of cardiac rhythm
  • Improved mental status
  • Normalization of vital signs

Nursing Care Plan 8: Acute Pain

NANDA Diagnosis: Acute Pain related to injury, surgical interventions, or tissue ischemia as evidenced by verbal reports of pain, protective behavior, and physiologic indicators

Assessment Data:

  • Self-report of pain (location, intensity, quality)
  • Facial grimacing, guarding behaviors
  • Restlessness, agitation
  • Tachycardia (when not attributable to hypovolemia)
  • Hypertension (in response to pain, despite hypovolemia)
  • Diaphoresis
  • Muscle tension
  • Limited movement
  • Pain scales indicating moderate to severe pain

Expected Outcomes:

  • Patient will experience reduced pain as evidenced by:
    • Verbalization of pain relief or acceptable pain level
    • Pain scores reduced to mild level (≤3/10) or patient’s acceptable level
    • Decreased physiological indicators of pain
    • Reduced guarding behaviors
    • Improved ability to participate in care activities
    • Improved rest/sleep patterns

Nursing Interventions with Rationales:

Nursing Interventions Rationale
Assess pain comprehensively using appropriate pain scale (numeric, FLACC, CPOT, etc.) at regular intervals and before/after interventions. Systematic pain assessment allows for objective evaluation of pain intensity and response to interventions. Different scales may be needed based on patient’s ability to communicate.
Believe patient’s report of pain and respond promptly. Pain is a subjective experience; validating the patient’s experience builds trust and improves pain management outcomes.
Administer prescribed analgesics, carefully considering hemodynamic status and using appropriate routes and dosing. Pharmacological management is often necessary for acute pain relief. In hypovolemic shock, medication selection and dosing should account for altered drug distribution and clearance.
Consider IV opioid titration in small increments for severe pain, with close hemodynamic monitoring. Opioids can cause vasodilation and hypotension, requiring cautious administration in hypovolemic patients. Small, frequent doses allow for titration to effect while monitoring for adverse effects.
Implement non-pharmacological pain management techniques: proper positioning, splinting of painful areas during movement, relaxation techniques. Non-pharmacological approaches can supplement medication effects and provide pain relief with minimal hemodynamic impact.
Anticipate painful procedures or activities and provide pre-emptive analgesia when appropriate. Pre-emptive analgesia is more effective than treating established pain and may reduce total analgesic requirements.
Document pain assessments, interventions, and patient responses consistently. Documentation facilitates continuity of care and evaluation of pain management effectiveness over time.
Provide a quiet, comfortable environment and minimize unnecessary stimulation. Environmental factors can influence pain perception; reducing external stressors may help decrease pain intensity.
Monitor for respiratory depression when administering opioids, especially in patients with altered mental status or respiratory compromise. Opioid analgesics can cause respiratory depression, particularly in hypovolemic patients who may have altered drug metabolism.
Consider regional analgesia techniques (epidural, nerve blocks) in consultation with pain specialists for certain injuries or surgical procedures. Regional techniques can provide excellent analgesia with potentially fewer systemic effects than parenteral opioids.

Evaluation:

Evaluate the patient’s response to interventions by assessing:

  • Pain intensity scores trending downward
  • Patient’s subjective reports of pain relief
  • Decreased physiological indicators of pain
  • Improved ability to participate in necessary care activities
  • Improved rest and comfort
  • Absence of analgesic-related adverse effects

Nursing Care Plan 9: Ineffective Peripheral Tissue Perfusion

NANDA Diagnosis: Ineffective Peripheral Tissue Perfusion related to decreased arterial blood flow secondary to hypovolemia as evidenced by altered skin characteristics, diminished pulses, and delayed capillary refill

Assessment Data:

  • Diminished or absent peripheral pulses
  • Delayed capillary refill (>3 seconds)
  • Cool extremities
  • Pale or mottled skin color
  • Decreased sensation in extremities
  • Edema
  • Pain in extremities
  • Decreased motor function
  • Abnormal Ankle-Brachial Index (<0.9)

Expected Outcomes:

  • Patient will demonstrate improved peripheral tissue perfusion as evidenced by:
    • Palpable peripheral pulses
    • Capillary refill <3 seconds
    • Warm extremities
    • Normal skin color
    • Maintained or improved sensation
    • Reduced or absent edema
    • Reduced or absent pain in extremities
    • Maintained or improved motor function

Nursing Interventions with Rationales:

Nursing Interventions Rationale
Assess peripheral circulation in all extremities q1-2h: pulses, capillary refill, skin color, temperature, sensation, and movement. Systematic assessment allows for early detection of changes in perfusion status and potential complications like compartment syndrome or ischemia.
Document findings using a consistent scale (e.g., pulses: 0 = absent, +1 = weak, +2 = normal, +3 = bounding). Standardized documentation improves communication among healthcare team members and facilitates tracking changes over time.
Use Doppler ultrasound to assess pulses that are not palpable. Doppler assessment can detect blood flow even when pulses are too weak to palpate, providing more accurate assessment of perfusion.
Implement volume resuscitation as prescribed to restore intravascular volume and improve tissue perfusion. Adequate circulating volume is essential for peripheral tissue perfusion; fluid resuscitation is the primary intervention for hypovolemic shock.
Position extremities at or below heart level unless contraindicated. Facilitates arterial inflow and maximizes perfusion pressure to the extremities.
Avoid pressure on extremities; do not elevate knees with pillows or use knee gatch on bed. Pressure can further compromise blood flow in already hypoperfused tissues; knee flexion may impair popliteal blood flow.
Remove constrictive clothing, dressings, or devices that could impair circulation. External pressure can further compromise blood flow to extremities.
Implement measures to maintain normothermia, but avoid local heat application to extremities. Hypothermia causes vasoconstriction and worsens peripheral perfusion. However, heat application to poorly perfused extremities can increase metabolic demands beyond oxygen supply, potentially worsening tissue injury.
Monitor for signs of compartment syndrome: pain out of proportion to injury, paresthesias, pallor, pulselessness, and paralysis. Compartment syndrome is a serious complication of hypoperfusion and fluid resuscitation that requires immediate surgical intervention.
Implement pressure ulcer prevention strategies, particularly for areas with compromised perfusion. Hypoperfused tissues are at increased risk for pressure injury due to reduced oxygen delivery and impaired cellular metabolism.

Critical Assessment Alert

Remember that the “5 P’s” of acute limb ischemia (Pain, Pallor, Pulselessness, Paresthesia, Paralysis) are late signs. Early intervention is crucial to prevent tissue necrosis. Report significant changes in peripheral perfusion immediately.

Evaluation:

Evaluate the patient’s response to interventions by assessing:

  • Improvement in peripheral pulses
  • Normalization of capillary refill
  • Warming of extremities
  • Improved skin color
  • Maintained or improved sensation and motor function
  • Absence of complications (compartment syndrome, pressure injuries)

Nursing Care Plan 10: Decreased Intracranial Adaptive Capacity

NANDA Diagnosis: Decreased Intracranial Adaptive Capacity related to cerebral hypoperfusion secondary to hypovolemic shock as evidenced by altered level of consciousness and pupillary changes

Assessment Data:

  • Altered level of consciousness (lethargy, confusion, restlessness)
  • Changes in pupillary response
  • Decreased Glasgow Coma Scale score
  • Hypotension (SBP <90 mmHg)
  • Decreased cerebral perfusion pressure
  • Changes in respiratory pattern
  • Headache
  • Dizziness
  • Visual disturbances

Expected Outcomes:

  • Patient will maintain adequate cerebral perfusion as evidenced by:
    • Return to baseline mental status
    • Normal pupillary response (equal, round, reactive to light)
    • Glasgow Coma Scale score of 14-15 or baseline
    • Maintained SBP >90 mmHg or within patient’s normal range
    • Absence of headache, dizziness, and visual disturbances
    • Normal respiratory pattern

Nursing Interventions with Rationales:

Nursing Interventions Rationale
Perform frequent neurological assessments q1h or more frequently if unstable, including GCS, pupil size and reactivity, limb strength, and orientation. Serial neurological assessments allow early detection of cerebral hypoperfusion and potential secondary injury.
Restore and maintain adequate systemic blood pressure through fluid resuscitation and vasopressors as prescribed. Cerebral perfusion pressure (CPP) depends on mean arterial pressure (MAP); hypotension is a primary cause of secondary brain injury.
Position head in midline position with head of bed elevated 30° if not contraindicated by hemodynamic status. Promotes venous drainage from the brain and may help optimize cerebral perfusion; however, in severe hypovolemia, flat positioning may be necessary to maintain CPP.
Avoid activities that increase intracranial pressure (ICP): coughing, straining, Valsalva maneuver. These activities can temporarily increase ICP and reduce cerebral perfusion.
Maintain PaO2 >80 mmHg and PaCO2 35-45 mmHg. Both hypoxemia and extreme CO2 levels can affect cerebral blood flow; hypoxemia causes vasodilation while hypocapnia causes vasoconstriction.
Administer mannitol or hypertonic saline as prescribed for signs of increased ICP. Osmotic agents can temporarily reduce ICP by drawing fluid from brain tissue into the intravascular space.
Monitor for seizure activity and administer antiepileptic medications as prescribed. Cerebral hypoperfusion increases seizure risk; seizures increase cerebral metabolic demands and can worsen injury.
Maintain normoglycemia (glucose 80-180 mg/dL). Both hyperglycemia and hypoglycemia can worsen cerebral injury; tight glucose control is essential.
Monitor for signs of increased ICP: decreased LOC, pupillary changes, Cushing’s triad (hypertension, bradycardia, irregular respirations). Cushing’s triad is a late sign of increased ICP and impending brain herniation, requiring immediate intervention.
Provide a calm, quiet environment with minimal stimulation. Reduces metabolic demands on the brain and may help prevent increases in ICP.

Evaluation:

Evaluate the patient’s response to interventions by assessing:

  • Level of consciousness trending toward baseline
  • Pupillary responses
  • Glasgow Coma Scale score
  • Stability of vital signs
  • Improved orientation and cognition
  • Resolution of neurologic symptoms
  • Adequate cerebral perfusion pressure (if monitored)

Nursing Care Plan 11: Risk for Electrolyte Imbalance

NANDA Diagnosis: Risk for Electrolyte Imbalance related to fluid volume deficit, fluid shifts, acid-base imbalance, and treatment regimen

Risk Factors:

  • Rapid fluid administration
  • Administration of large volumes of isotonic fluids
  • Blood product administration
  • Renal hypoperfusion
  • Acid-base disturbances
  • Endocrine dysfunction secondary to shock
  • Gastrointestinal losses (vomiting, diarrhea, NG suction)
  • Cellular damage from traumatic injury
  • Medications (diuretics, steroids, vasopressors)

Expected Outcomes:

  • Patient will maintain electrolyte levels within normal ranges:
    • Sodium: 135-145 mEq/L
    • Potassium: 3.5-5.0 mEq/L
    • Calcium: 8.5-10.5 mg/dL
    • Magnesium: 1.5-2.5 mEq/L
    • Phosphorus: 2.5-4.5 mg/dL
    • Chloride: 96-106 mEq/L
  • Patient will remain free from signs and symptoms of electrolyte imbalances

Nursing Interventions with Rationales:

Nursing Interventions Rationale
Monitor serum electrolytes, BUN, creatinine, and acid-base status q4-6h initially, then as indicated by patient’s condition. Serial monitoring allows for early detection of imbalances and evaluation of treatment effectiveness.
Assess for clinical manifestations of electrolyte imbalances:
  • Hypo/hypernatremia: altered mental status, seizures
  • Hypo/hyperkalemia: cardiac dysrhythmias, muscle weakness
  • Hypocalcemia: tetany, prolonged QT interval
  • Hypomagnesemia: tremors, dysrhythmias
 Clinical manifestations may appear before laboratory abnormalities are detected or may indicate the severity of the imbalance.
Monitor continuous cardiac monitoring for dysrhythmias associated with electrolyte imbalances. Potassium, calcium, and magnesium abnormalities commonly manifest as cardiac dysrhythmias.
Monitor ECG for changes indicating electrolyte imbalances:
  • Hyperkalemia: peaked T waves, widened QRS
  • Hypokalemia: U waves, flat T waves
  • Hypocalcemia: prolonged QT interval
 ECG changes often precede symptomatic electrolyte imbalances and can guide early intervention.
Administer IV fluids with appropriate electrolyte content as prescribed. Selection of appropriate fluid type can help prevent or correct electrolyte imbalances during resuscitation.
Administer electrolyte replacement therapies as prescribed, monitoring infusion rates carefully. Too rapid correction of electrolyte abnormalities can cause adverse effects (e.g., rapid sodium correction can lead to osmotic demyelination syndrome).
Monitor renal function through urine output, BUN, creatinine, and urine electrolytes when ordered. Renal function affects electrolyte excretion and balance; impaired renal function increases risk for imbalances.
Maintain accurate fluid balance records, including all intake and output sources. Fluid balance affects electrolyte concentration; accurate documentation helps guide treatment decisions.
Monitor for signs of third-spacing (edema, ascites) that can affect fluid and electrolyte distribution. Third-spacing can create apparent hypovolemia despite adequate fluid administration and affect serum electrolyte measurements.
Monitor acid-base status through ABGs and correct underlying abnormalities as prescribed. Acid-base disturbances can cause or exacerbate electrolyte imbalances, particularly potassium abnormalities.

Evaluation:

Evaluate the patient’s status by assessing:

  • Serum electrolyte levels trending toward or remaining within normal ranges
  • Absence of clinical manifestations of electrolyte imbalances
  • Normal ECG without electrolyte-related changes
  • Stable cardiac rhythm
  • Improving renal function
  • Normalized acid-base balance

Nursing Care Plan 12: Risk for Impaired Renal Function

NANDA Diagnosis: Risk for Impaired Renal Function related to decreased renal perfusion secondary to hypovolemic shock

Risk Factors:

  • Renal hypoperfusion due to hypovolemia
  • Ischemia-reperfusion injury following resuscitation
  • Nephrotoxic medications (antibiotics, contrast dyes, NSAIDs)
  • Myoglobinuria from traumatic muscle injury
  • Advanced age
  • Pre-existing renal disease
  • Prolonged hypotension
  • Sepsis

Expected Outcomes:

  • Patient will maintain adequate renal function as evidenced by:
    • Urine output >0.5ml/kg/hr
    • BUN and creatinine within normal limits or trending toward normal
    • Stable electrolyte levels
    • Acid-base balance within normal limits
    • Normal urine characteristics (color, clarity, specific gravity)
    • Absence of signs of fluid overload or uremia

Nursing Interventions with Rationales:

Nursing Interventions Rationale
Monitor urine output hourly, maintaining a goal of >0.5ml/kg/hr. Urine output is an important indicator of renal perfusion; oliguria is an early sign of acute kidney injury.
Monitor serum creatinine, BUN, estimated GFR, and electrolytes at least daily. These laboratory values help assess renal function and detect acute kidney injury early.
Calculate and trend BUN/creatinine ratio. Elevated ratio (>20:1) suggests prerenal azotemia, which may be reversible with improved renal perfusion.
Monitor urine specific gravity and osmolality as indicators of concentrating ability. Failure to concentrate urine (fixed specific gravity around 1.010) may indicate acute tubular necrosis.
Optimize hemodynamic status through appropriate fluid resuscitation and vasopressors if needed. Maintaining adequate renal perfusion pressure (MAP typically >65 mmHg) is essential for preventing ischemic renal injury.
Avoid nephrotoxic medications when possible or adjust dosing based on renal function. Nephrotoxic drugs can compound injury from hypoperfusion; dose adjustments may be necessary to prevent accumulation.
If contrast studies are necessary, implement nephroprotective measures (pre-hydration, N-acetylcysteine as ordered). Contrast-induced nephropathy is a risk in patients with compromised renal function; preventative measures may reduce this risk.
Monitor for signs of excessive fluid administration: crackles, edema, jugular vein distention, and weight gain. Fluid overload can increase renal venous pressure and worsen kidney function, particularly in patients with acute kidney injury.
If myoglobinuria is suspected (dark urine, crush injuries), implement measures to prevent tubular precipitation:
  • Aggressive hydration
  • Urine alkalinization if ordered
  • Mannitol if ordered
 Myoglobin can precipitate in renal tubules and cause direct tubular injury, particularly in acidic urine. Alkalinization and dilution help prevent precipitation.
Monitor cumulative fluid balance and reassess fluid requirements regularly. Fluid requirements change over the course of treatment; overly aggressive resuscitation may lead to fluid overload as the patient stabilizes.

Evaluation:

Evaluate the patient’s response to interventions by assessing:

  • Urine output trends
  • Changes in BUN and creatinine levels
  • Electrolyte balance
  • Acid-base status
  • Urine characteristics
  • Signs of fluid balance (edema, weight, JVD)

Nursing Care Plan 13: Deficient Knowledge

NANDA Diagnosis: Deficient Knowledge related to unfamiliar information regarding condition, prognosis, and treatment as evidenced by questions, statements of misconception, or anxiety regarding care

Assessment Data:

  • Verbalized questions about condition and treatment
  • Statements indicating misconceptions
  • Anxiety regarding treatment and procedures
  • Expressed concern about future implications
  • Lack of familiarity with medical terminology
  • Uncertainty about self-care requirements
  • Unfamiliarity with medical resources

Expected Outcomes:

  • Patient/family will demonstrate increased knowledge about hypovolemic shock as evidenced by:
    • Verbalization of accurate information about condition, treatment, and prognosis
    • Ability to explain rationales for treatments and procedures
    • Demonstration of necessary self-care activities
    • Recognition of signs and symptoms requiring medical attention
    • Identification of appropriate resources for information and support

Nursing Interventions with Rationales:

Nursing Interventions Rationale
Assess patient’s/family’s current level of understanding, learning needs, and preferred learning style. Assessment provides baseline for planning education and allows tailoring to individual needs and preferences.
Provide information in simple, clear language, avoiding medical jargon. Use of plain language improves comprehension and retention, especially during times of stress when cognitive processing may be impaired.
Provide information in manageable amounts, pacing education based on patient’s condition and readiness to learn. Information overload can impair retention; prioritizing essential information and delivering it in stages improves comprehension.
Include explanations about:
  • Basic pathophysiology of hypovolemic shock
  • Purpose and expected effects of treatments
  • Importance of fluid and electrolyte balance
  • Expected recovery trajectory
  • Prevention of complications
 Understanding the rationale for treatments improves cooperation and may reduce anxiety. Knowledge about potential complications promotes early recognition and reporting.
Use multiple teaching methods (verbal, written, demonstrative) based on patient’s learning preferences. Multiple modalities reinforce learning and accommodate different learning styles. Written materials provide reference after discharge.
Encourage questions and provide honest answers; acknowledge when you don’t know something and offer to find information. Creates an environment conducive to learning and builds trust; demonstrates respect for patient’s/family’s need for information.
Validate understanding by asking patient/family to explain or demonstrate concepts in their own words. Teach-back method confirms comprehension better than simply asking “Do you understand?” which often yields affirmative responses regardless of actual understanding.
Provide specific instructions about follow-up care, activity restrictions, medication management, and recognition of complications. Clear discharge instructions improve adherence to treatment plans and enable early recognition of problems.
Connect patient/family with appropriate resources for ongoing support and information. Resources provide continuity of information and support after discharge, reinforcing and expanding on hospital education.
Document educational content provided, teaching methods used, and patient’s level of understanding. Documentation ensures continuity of care and allows other healthcare providers to reinforce and build upon previous teaching.

Evaluation:

Evaluate the patient’s/family’s response to education by assessing:

  • Ability to accurately describe condition, treatments, and rationales
  • Demonstration of required skills (if applicable)
  • Identification of signs/symptoms requiring medical attention
  • Verbalization of appropriate follow-up plan
  • Decreased anxiety related to knowledge deficits
  • Questions that demonstrate increasing sophistication of understanding

Nursing Care Plan 14: Disturbed Body Image

NANDA Diagnosis: Disturbed Body Image related to trauma, surgical interventions, or functional changes as evidenced by verbalization of concerns, fear of rejection, negative feelings about body, and avoidance of looking at affected body part

Assessment Data:

  • Verbalized negative feelings about body or appearance
  • Refusal to look at affected body part
  • Expressed concerns about others’ reactions
  • Changes in social involvement
  • Self-isolating behaviors
  • Physical or emotional withdrawal
  • Changes in ability to perform activities of daily living
  • Visible trauma, scarring, or medical devices (drains, colostomy, IV lines)

Expected Outcomes:

  • Patient will demonstrate healthy adaptation to changes in appearance or function as evidenced by:
    • Willingness to view and touch affected body parts
    • Participation in self-care activities
    • Verbalization of feelings about body changes
    • Identification of personal strengths unrelated to physical appearance
    • Setting realistic goals for adaptation
    • Maintenance of social relationships

Nursing Interventions with Rationales:

Nursing Interventions Rationale
Establish therapeutic relationship based on trust and acceptance; approach patient with empathy and without judgment. Therapeutic relationship provides safe environment for patient to express feelings about body changes; nurse’s acceptance models positive attitude.
Encourage verbalization of feelings regarding changes in appearance or function; validate these feelings as normal. Expression of feelings helps patient process emotional responses to body changes; validation normalizes these responses and reduces isolation.
Assess for signs of depression, anxiety, or grief related to body changes. Body image disturbances often coexist with psychological distress that may require additional intervention.
Involve patient in care decisions and self-care activities as condition permits. Participation in care promotes sense of control and self-efficacy, which can improve body image and self-concept.
Use a gradual, systematic approach to help patient view and touch altered body parts or devices. Graduated exposure helps reduce anxiety and promotes integration of changes into body image; progressing at patient’s pace prevents overwhelming emotional responses.
Provide factual information about expected healing, recovery, and adaptation. Accurate information helps patient develop realistic expectations about appearance and function, reducing anxiety about unknown outcomes.
Teach strategies to minimize visible changes (positioning, clothing, adaptive devices) while encouraging acceptance. Practical strategies provide immediate coping mechanisms while patient works toward long-term acceptance.
Encourage contact with significant others who can provide positive feedback and support. Positive social interactions reinforce self-worth and reduce fears about rejection by others.
Connect patient with appropriate resources: support groups, rehabilitation services, counseling, peer visitors. Contact with others who have successfully adapted to similar changes provides hope and practical coping strategies.
Acknowledge progress and positive coping; reinforce patient’s strengths and abilities. Positive reinforcement encourages continued adaptive behaviors; focusing on abilities rather than deficits promotes positive self-concept.

Evaluation:

Evaluate the patient’s response to interventions by assessing:

  • Willingness to look at and touch affected body parts
  • Participation in self-care activities
  • Verbalization of feelings about body changes
  • Statements reflecting realistic acceptance and adaptation
  • Maintenance of social relationships
  • Absence of maladaptive coping behaviors

Nursing Care Plan 15: Powerlessness

NANDA Diagnosis: Powerlessness related to acute illness, healthcare environment, and treatment regimen as evidenced by expressions of having no control, dependency on others, and passivity

Assessment Data:

  • Verbalized feelings of having no control over situation
  • Expressions of helplessness or hopelessness
  • Passivity, reluctance to participate in decision-making
  • Dependency on others for care
  • Reluctance to express feelings
  • Anger, frustration, or withdrawal
  • Limited participation in self-care activities
  • Expressions of doubt about role performance

Expected Outcomes:

  • Patient will demonstrate increased sense of control and participation as evidenced by:
    • Verbalization of areas where control can be exercised
    • Active participation in care decisions when possible
    • Engagement in self-care activities as condition allows
    • Expression of feelings about situation and treatment
    • Use of available support systems
    • Setting realistic goals for recovery

Nursing Interventions with Rationales:

Nursing Interventions Rationale
Establish a therapeutic relationship based on trust and respect; acknowledge patient’s feelings without dismissing them. Validation of feelings helps patient feel heard and respected; therapeutic relationship provides foundation for interventions to reduce powerlessness.
Assess patient’s perception of the situation and sources of powerlessness. Understanding patient’s specific concerns allows for targeted interventions addressing actual rather than assumed sources of powerlessness.
Provide information about condition, treatment options, and expected course in terms patient can understand. Knowledge reduces uncertainty and enhances sense of control; understanding the situation helps patient make informed choices when possible.
Offer choices whenever possible, even in small matters (timing of care, positioning, food preferences). Having choices, even limited ones, helps restore sense of control and reduces feelings of powerlessness.
Involve patient in care planning and goal-setting to the extent possible. Participation in planning promotes ownership of care process and reinforces patient’s role as active participant rather than passive recipient.
Encourage and support participation in self-care activities as condition allows. Self-care promotes independence and demonstrates patient’s capabilities despite limitations imposed by illness.
Acknowledge and reinforce patient’s strengths and capabilities. Recognition of strengths counters feelings of helplessness and builds confidence in ability to cope with challenges.
Explain procedures, equipment, and environmental aspects that may seem intimidating. Unfamiliar medical environment and technology can increase feelings of powerlessness; explanation helps demystify surroundings.
Support family and significant others in providing appropriate assistance without fostering dependency. Family members can inadvertently reinforce powerlessness through overprotection; guidance helps them support patient’s independence.
Advocate for patient’s preferences and needs with healthcare team. Advocacy demonstrates respect for patient’s autonomy and helps ensure preferences are considered in treatment decisions.

Empowerment Strategies

Even in critical illness situations like hypovolemic shock, finding small opportunities for patient participation and control can significantly impact psychological well-being and recovery. Consider creating a simple daily plan with the patient that includes their preferences for care routines when clinically stable.

Evaluation:

Evaluate the patient’s response to interventions by assessing:

  • Expressions of increased control over situation
  • Active participation in decision-making when possible
  • Engagement in self-care activities
  • Decreased expressions of helplessness or hopelessness
  • Use of available resources and support systems
  • Setting and working toward personal goals

References

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