Nursing Diagnosis Care Plan for Hypovolemic Shock: Comprehensive Guide

What is Hypovolemic Shock?

Hypovolemic shock is a critical medical condition that occurs when there is severe fluid loss, leading to a decreased volume of circulating blood. This reduction in intravascular volume impairs the heart’s ability to pump enough blood to the body, resulting in inadequate tissue perfusion and oxygen delivery to vital organs. The primary cause of hypovolemic shock is often significant blood loss, such as from trauma or gastrointestinal bleeding. However, it can also be triggered by other forms of fluid loss, including severe dehydration due to vomiting, diarrhea, extensive burns, or excessive sweating.

In hypovolemic shock, the body attempts to compensate for the reduced blood volume by increasing heart rate and constricting blood vessels to maintain blood pressure. However, these compensatory mechanisms eventually fail if the underlying fluid loss is not addressed promptly. Without timely and effective intervention, hypovolemic shock can lead to organ damage, failure, and even death. Recognizing the signs and symptoms of hypovolemic shock and implementing rapid, appropriate nursing care are crucial for improving patient outcomes.

The main goals of nursing care for hypovolemic shock are to identify and treat the underlying cause of fluid loss, restore intravascular volume, optimize oxygen delivery to tissues, and prevent complications. This requires a systematic approach involving rapid assessment, timely interventions, and continuous monitoring.

Nursing Care Plans & Management

The nursing management of hypovolemic shock demands a swift and coordinated response. It begins with a rapid and thorough assessment to pinpoint the cause and severity of the fluid volume deficit. Simultaneously, interventions are initiated to restore circulating volume and support vital organ function. Key aspects of nursing care include the administration of intravenous fluids, monitoring hemodynamic status, providing oxygen therapy, and addressing the underlying cause of shock. Effective communication and collaboration within the healthcare team are essential to ensure timely and appropriate adjustments to the care plan.

Nursing Problem Priorities

Nursing priorities when caring for a patient in hypovolemic shock are centered on stabilizing the patient’s condition and preventing further deterioration. These priorities include:

• Restoring Fluid Volume: Rapidly replacing lost fluids to improve cardiac output and tissue perfusion.
• Optimizing Tissue Perfusion: Ensuring adequate oxygen and nutrient delivery to vital organs.
• Identifying and Treating the Cause: Determining and addressing the underlying reason for hypovolemic shock to prevent recurrence.
• Preventing Complications: Monitoring for and mitigating potential complications such as organ damage and failure.
• Reducing Anxiety: Providing emotional support and reducing patient anxiety related to their critical condition.

Nursing Assessment

A comprehensive nursing assessment is vital for identifying hypovolemic shock and guiding appropriate interventions. This assessment includes both subjective and objective data collection.

Assess for the following subjective and objective data:

• Abnormal Arterial Blood Gases (ABGs): Evaluate for hypoxemia (low blood oxygen levels) and metabolic acidosis, indicative of impaired tissue oxygenation and anaerobic metabolism.
• Prolonged Capillary Refill Time: A capillary refill time exceeding 3 seconds suggests poor peripheral perfusion.
• Cardiac Dysrhythmias: Irregular heart rhythms can arise from electrolyte imbalances, hypoxia, and myocardial ischemia due to decreased perfusion.
• Altered Level of Consciousness: Changes in mental status, ranging from restlessness and anxiety to confusion and lethargy, reflect decreased cerebral perfusion.
• Cold and Clammy Skin: Vasoconstriction to shunt blood to vital organs results in cool, pale, and clammy skin, particularly in the extremities.
• Decreased Skin Turgor: Reduced skin elasticity, especially in areas like the forehead or sternum, indicates dehydration.
• Dizziness and Weakness: These are common symptoms due to decreased cerebral blood flow and overall hypoperfusion.
• Dry Mucous Membranes: Dehydration leads to dryness of the oral mucosa and tongue.
• Increased Thirst: The body’s response to fluid deficit is to stimulate thirst.
• Narrowing of Pulse Pressure: The difference between systolic and diastolic blood pressure decreases as stroke volume falls.
• Orthostatic Hypotension: A significant drop in blood pressure upon standing (systolic decrease of 20 mmHg or diastolic decrease of 10 mmHg) indicates fluid volume depletion.
• Tachycardia: An elevated heart rate is an early compensatory mechanism to maintain cardiac output despite reduced stroke volume.
• Variable Urine Output: Urine output may initially be normal but will decrease to below 20-30 mL/hr as the kidneys attempt to conserve fluid. In severe shock, urine output may be minimal or absent.

Assessing skin turgor to evaluate for dehydration in hypovolemic shock.

Alt text: Nurse assessing skin turgor on a patient’s forearm to check for dehydration, a key indicator of hypovolemic shock.

Assess for factors related to the cause of hypovolemic shock:

• Active Fluid Volume Loss: Identify sources of fluid loss such as:
  • External losses: Hemorrhage (evident or occult), gastrointestinal losses (vomiting, diarrhea), excessive diuresis, wound drainage, burns.
  • Internal shifts: Third spacing of fluid, internal bleeding not immediately visible.
• Inadequate Fluid Intake: Consider conditions that limit oral intake or access to fluids.
• Trauma: Assess for injuries that could lead to blood loss or fluid shifts.
• Medical History: Review patient history for conditions predisposing to hypovolemia, such as gastrointestinal disorders, renal disease, or bleeding disorders.
• Medications: Identify medications that may contribute to fluid loss, such as diuretics.

Nursing Diagnosis

Based on the assessment findings, a relevant nursing diagnosis for hypovolemic shock is Deficient Fluid Volume related to active fluid loss, as evidenced by [list specific assessment findings, e.g., decreased blood pressure, tachycardia, decreased urine output, altered mental status].

This diagnosis guides the development of a tailored nursing care plan focused on restoring fluid volume and addressing the underlying cause of hypovolemic shock.

Nursing Goals

The overarching goals for nursing care in hypovolemic shock are to:

• Restore and maintain adequate fluid volume.
• Improve tissue perfusion and oxygenation.
• Identify and treat the underlying cause of hypovolemia.
• Prevent complications of hypovolemic shock.
• Reduce patient anxiety and provide emotional support.

Nursing Interventions and Actions

Nursing interventions for hypovolemic shock are multifaceted and require a collaborative approach. These interventions are focused on addressing the nursing priorities outlined earlier.

1. Managing Decreased Cardiac Output

Decreased cardiac output is a central problem in hypovolemic shock, resulting from reduced preload due to fluid volume loss. Nursing interventions aim to improve cardiac output by restoring intravascular volume and supporting cardiac function.

Nursing Interventions:

• Administer Fluid and Blood Replacement Therapy as Prescribed:
  • Rationale: Fluid replacement is the cornerstone of treatment for hypovolemic shock. Crystalloids (e.g., normal saline, lactated Ringer’s) are typically the initial fluids of choice to rapidly expand intravascular volume. Colloids (e.g., albumin) may be used to increase oncotic pressure and retain fluid within the vascular space. Blood products (packed red blood cells, fresh frozen plasma, platelets) are necessary in cases of significant blood loss.
  • Action: Initiate intravenous fluid administration as per physician orders. Use large-bore IV catheters for rapid infusion. Monitor infusion rates closely, especially in patients with cardiac or renal compromise, to prevent fluid overload. Ensure safe blood transfusion practices, including proper patient identification, blood product verification, and monitoring for transfusion reactions. Utilize fluid warmers, especially for large-volume infusions, to prevent hypothermia.
• Assess Heart Rate and Blood Pressure Frequently:
  • Rationale: Heart rate and blood pressure are critical indicators of hemodynamic status. Tachycardia and hypotension are hallmark signs of hypovolemic shock. Intra-arterial blood pressure monitoring may be indicated for continuous and accurate blood pressure assessment in unstable patients.
  • Action: Monitor vital signs (heart rate, blood pressure, respiratory rate, temperature, oxygen saturation) every 5-15 minutes initially, and as frequently as needed based on patient condition. Assess for trends and report significant changes to the physician promptly. Use continuous ECG monitoring to detect dysrhythmias.
• Assess Capillary Refill Time:
  • Rationale: Capillary refill time provides a quick assessment of peripheral perfusion. Prolonged refill time (>3 seconds) indicates poor tissue perfusion.
  • Action: Assess capillary refill in a peripheral location (e.g., nail bed, fingertip). Document findings and correlate with other perfusion parameters.
• Assess Respiratory Rate, Rhythm, and Breath Sounds:
  • Rationale: Respiratory status is affected by hypovolemic shock. Rapid, shallow respirations and adventitious breath sounds (crackles, wheezes) may indicate respiratory distress or fluid overload.
  • Action: Monitor respiratory rate, depth, and effort. Auscultate breath sounds to assess for abnormalities. Monitor oxygen saturation continuously using pulse oximetry.
• Monitor Oxygen Saturation and Arterial Blood Gases (ABGs):
  • Rationale: Oxygen saturation and ABGs provide information about oxygenation and acid-base balance. Hypoxemia and metabolic acidosis are common in hypovolemic shock.
  • Action: Maintain oxygen saturation above 90% by administering supplemental oxygen as needed. Obtain ABGs as ordered to assess oxygenation, ventilation, and acid-base status.
• Monitor Central Venous Pressure (CVP), Pulmonary Artery Diastolic Pressure (PADP), Pulmonary Capillary Wedge Pressure (PCWP), and Cardiac Output/Cardiac Index (if indicated):
  • Rationale: Invasive hemodynamic monitoring provides detailed information about fluid volume status and cardiac function. CVP reflects right atrial pressure and preload. PADP and PCWP reflect left ventricular preload. Cardiac output and cardiac index provide objective measures of cardiac performance.
  • Action: If indicated, assist with the insertion of central venous and/or pulmonary artery catheters. Monitor hemodynamic parameters as ordered and interpret trends in relation to fluid resuscitation and patient response.
• Assess Level of Consciousness:
  • Rationale: Neurological status is sensitive to changes in cerebral perfusion. Restlessness, anxiety, and confusion are early signs of cerebral hypoxia.
  • Action: Assess level of consciousness frequently using a standardized scale (e.g., Glasgow Coma Scale). Monitor for changes in mentation, orientation, and responsiveness.
• Assess Urine Output:
  • Rationale: Urine output is an indicator of renal perfusion and overall fluid volume status. Oliguria (decreased urine output) is a sign of inadequate renal perfusion.
  • Action: Insert a urinary catheter to monitor urine output hourly. Maintain urine output at least 0.5 mL/kg/hr or 30 mL/hr in adults, unless otherwise ordered.
• Assess Skin Color, Temperature, and Moisture:
  • Rationale: Skin assessment provides information about peripheral perfusion. Cool, pale, and clammy skin are signs of vasoconstriction and decreased cardiac output.
  • Action: Assess skin color, temperature, and moisture frequently. Note any pallor, cyanosis, or mottling.
• Provide Electrolyte Replacement as Prescribed:
  • Rationale: Electrolyte imbalances can occur in hypovolemic shock due to fluid shifts, renal dysfunction, and fluid resuscitation. Electrolyte imbalances can exacerbate cardiac dysrhythmias.
  • Action: Monitor serum electrolyte levels (sodium, potassium, calcium, magnesium). Administer electrolyte replacements as prescribed to correct imbalances.
• Utilize Fluid Warmer or Rapid Fluid Infuser (if possible):
  • Rationale: Rapid infusion of large volumes of cold fluids can contribute to hypothermia and cardiac instability. Fluid warmers help maintain core body temperature during rapid fluid resuscitation. Rapid infusers can deliver large volumes of fluid quickly when needed.
  • Action: Use fluid warmers for large-volume crystalloid and blood product infusions. Consider using a rapid fluid infuser in cases of severe hypovolemic shock requiring extremely rapid volume replacement.

2. Improving Deficiencies in Fluid Volume

Addressing the underlying fluid volume deficit is paramount in managing hypovolemic shock. Nursing interventions focus on identifying and correcting the cause of fluid loss and restoring intravascular volume.

Nursing Interventions:

• Monitor Blood Pressure for Orthostatic Changes:
  • Rationale: Orthostatic hypotension is a sensitive indicator of fluid volume deficit. Significant drops in blood pressure upon standing suggest a considerable reduction in circulating blood volume.
  • Action: Assess for orthostatic hypotension by measuring blood pressure and heart rate in supine, sitting, and standing positions (if patient condition allows). A drop in systolic BP of >20 mmHg or diastolic BP of >10 mmHg, or an increase in heart rate of >20 bpm from supine to standing is considered positive for orthostatic hypotension.
• Assess Heart Rate, Blood Pressure, and Pulse Pressure:
  • Rationale: These vital signs provide ongoing assessment of hemodynamic status and response to fluid resuscitation.
  • Action: Monitor heart rate, blood pressure, and calculate pulse pressure frequently. Note trends and report significant changes.
• Assess Level of Consciousness:
  • Rationale: Changes in mental status are early indicators of hypovolemia and decreased cerebral perfusion.
  • Action: Monitor level of consciousness and assess for restlessness, confusion, and changes in orientation.
• Monitor for Possible Sources of Fluid Loss:
  • Rationale: Identifying the source of fluid loss is crucial for targeted treatment.
  • Action: Thoroughly assess for potential sources of fluid loss, including:
    • Visible bleeding (external hemorrhage, wound drainage).
    • Gastrointestinal losses (vomiting, diarrhea, ostomy output).
    • Urinary losses (diuresis).
    • Insensible losses (sweating, burns).
• Assess Skin Turgor and Mucous Membranes:
  • Rationale: These assessments help evaluate hydration status. Decreased skin turgor and dry mucous membranes are signs of dehydration.
  • Action: Assess skin turgor and mucous membranes regularly. Note any signs of dehydration.
• Monitor Intake and Output (I&O):
  • Rationale: Accurate I&O measurement is essential for monitoring fluid balance and guiding fluid replacement therapy.
  • Action: Maintain accurate I&O records, including all oral and intravenous intake, urine output, liquid stool, emesis, wound drainage, and other measurable fluid losses.
• Monitor Coagulation Studies (if indicated):
  • Rationale: Coagulation studies (PT, PTT, INR, platelet count, fibrinogen) may be indicated in cases of hemorrhage or suspected coagulopathy.
  • Action: Monitor coagulation studies as ordered. Report abnormal results to the physician.
• Obtain Spun Hematocrit and Re-evaluate Regularly:
  • Rationale: Hematocrit can be used to assess fluid volume status and response to fluid resuscitation. Hematocrit typically decreases with fluid administration due to dilution.
  • Action: Obtain baseline hematocrit and repeat as ordered (e.g., every 30 minutes to 4 hours) to monitor response to fluid therapy and detect ongoing blood loss.
• Place Patient in Modified Trendelenburg Position (Passive Leg Raising):
  • Rationale: Passive leg raising (modified Trendelenburg) can temporarily increase venous return and cardiac preload, serving as a dynamic assessment of fluid responsiveness. It helps redistribute blood volume from the lower extremities to the central circulation.
  • Action: Position the patient in a modified Trendelenburg position (supine with legs elevated at approximately 20-30 degrees). Monitor vital signs (blood pressure, heart rate) for improvement. This position should be used cautiously and is contraindicated in patients with increased intracranial pressure. Avoid full Trendelenburg position as it can impede breathing.
• Administer Antidiarrheal or Antiemetic Medications (if indicated):
  • Rationale: If hypovolemia is caused by severe diarrhea or vomiting, these medications can help reduce ongoing fluid losses.
  • Action: Administer antidiarrheal or antiemetic medications as prescribed to control excessive gastrointestinal fluid losses.
• Encourage Oral Fluid Intake (if able and appropriate):
  • Rationale: Oral fluid intake is the preferred route of fluid replacement when the patient is able to tolerate oral fluids and is not contraindicated.
  • Action: Encourage oral fluid intake if the patient is alert, oriented, and not nauseated or vomiting. Provide fluids that are tolerated and appropriate for the patient’s condition (e.g., electrolyte solutions, clear liquids).
• Prepare to Administer Bolus of IV Fluids as Ordered:
  • Rationale: Rapid bolus administration of IV fluids is often necessary to rapidly restore intravascular volume in hypovolemic shock.
  • Action: Prepare to administer a bolus of 1-2 liters of crystalloid solution (e.g., normal saline, lactated Ringer’s) as ordered by the physician. Monitor patient response closely during and after bolus administration.
• Initiate IV Therapy with Large-Bore Peripheral IV Lines:
  • Rationale: Large-bore IV catheters (18 gauge or larger) are essential for rapid fluid administration. Multiple IV lines allow for simultaneous infusion of fluids, medications, and blood products.
  • Action: Initiate IV therapy, preferably with two large-bore peripheral IV lines. If peripheral access is difficult, consider a central venous catheter or intraosseous access.
• Administer Blood Products as Prescribed:
  • Rationale: Blood products are necessary to replace blood loss in cases of hemorrhagic shock. Packed red blood cells increase oxygen-carrying capacity. Fresh frozen plasma provides clotting factors. Platelets are given to treat thrombocytopenia or platelet dysfunction.
  • Action: Administer blood products (packed red blood cells, fresh frozen plasma, platelets, cryoprecipitate) as prescribed. Follow blood transfusion protocols meticulously. Type O Rh-negative blood (universal donor) may be used in emergency situations when crossmatched blood is not immediately available.
• Monitor Central Venous Pressure (CVP), Pulmonary Artery Diastolic Pressure (PADP), Pulmonary Capillary Wedge Pressure (PCWP), and Cardiac Output/Cardiac Index (if indicated):
  • Rationale: These hemodynamic parameters provide valuable information for guiding fluid resuscitation and assessing the patient’s response to treatment.
  • Action: Continuously monitor CVP, PADP, PCWP, and cardiac output/cardiac index (if being monitored invasively) to assess fluid volume status and cardiac function. Adjust fluid administration based on these parameters and physician orders.

3. Improving Cardiac Tissue Perfusion

Enhancing cardiac tissue perfusion is critical to prevent myocardial ischemia and maintain cardiac function during hypovolemic shock.

Nursing Interventions:

• Assess for Signs of Decreased Tissue Perfusion:
  • Rationale: Early recognition of decreased tissue perfusion is essential for timely intervention.
  • Action: Regularly assess for signs of decreased tissue perfusion, including:
    • Altered mental status (restlessness, confusion).
    • Prolonged capillary refill time.
    • Pallor, cyanosis, mottling, cool and clammy skin.
    • Weak or absent peripheral pulses.
    • Decreased urine output.
• Assess for Rapid Changes or Continued Shifts in Mental Status:
  • Rationale: Neurological status is a sensitive indicator of cerebral perfusion.
  • Action: Closely monitor neurological status and report any changes in level of consciousness, orientation, or responsiveness.
• Assess Capillary Refill:
  • Rationale: Capillary refill time is a simple bedside assessment of peripheral perfusion.
  • Action: Assess capillary refill time frequently and document findings.
• Observe for Pallor, Cyanosis, Mottling, and Cool or Clammy Skin; Assess Pulse Quality:
  • Rationale: These are visual and tactile signs of impaired peripheral perfusion due to vasoconstriction and decreased cardiac output.
  • Action: Regularly inspect skin color and temperature. Palpate peripheral pulses (radial, pedal) to assess quality and strength. Report absent peripheral pulses immediately.
• Record Blood Pressure Readings for Orthostatic Changes:
  • Rationale: Orthostatic hypotension indicates inadequate fluid volume and can compromise tissue perfusion when changing position.
  • Action: Assess for orthostatic hypotension as described previously. Implement safety measures to prevent falls if orthostatic hypotension is present.
• Use Pulse Oximetry to Monitor Oxygen Saturation and Pulse Rate:
  • Rationale: Pulse oximetry provides continuous non-invasive monitoring of oxygen saturation and heart rate.
  • Action: Continuously monitor oxygen saturation and pulse rate using pulse oximetry. Maintain oxygen saturation as ordered.
• Review Laboratory Data (ABGs, BUN, Creatinine, Electrolytes, Coagulation Studies):
  • Rationale: Laboratory data provide objective information about organ function, oxygenation, acid-base balance, and coagulation status, which are important indicators of tissue perfusion and potential complications.
  • Action: Review laboratory results and report abnormalities to the physician. Monitor trends in lab values to assess patient response to treatment.
• Assist with Position Changes:
  • Rationale: Gradual position changes can minimize orthostatic hypotension and improve comfort.
  • Action: Assist patients with position changes slowly and monitor for dizziness or lightheadedness. Elevate the head of the bed as tolerated to improve respiratory function and comfort.
• Provide Oxygen Therapy if Indicated:
  • Rationale: Supplemental oxygen increases the amount of oxygen available to tissues, improving oxygen delivery and tissue perfusion.
  • Action: Administer oxygen therapy as prescribed to maintain adequate oxygen saturation. Monitor patient response to oxygen therapy.
• Administer IV Fluids as Ordered:
  • Rationale: IV fluid administration is essential to restore intravascular volume and improve cardiac output, which are critical for tissue perfusion.
  • Action: Continue IV fluid administration as ordered, monitoring patient response and adjusting infusion rates as needed.

4. Monitoring and Preventing Complications

Preventing complications is a crucial aspect of nursing care in hypovolemic shock, as it can have significant long-term consequences.

Nursing Interventions:

• Assess for Underlying Causes of Hypovolemia:
  • Rationale: Identifying and addressing the underlying cause of hypovolemic shock is essential to prevent recurrence and guide treatment.
  • Action: Thoroughly investigate potential causes of hypovolemic shock, including trauma, bleeding, gastrointestinal losses, burns, and dehydration.
• Evaluate and Document Injuries (if trauma-related):
  • Rationale: In trauma patients, a systematic assessment is needed to identify all injuries, prioritize treatment, and guide interventions. The primary survey (ABCDE – Airway, Breathing, Circulation, Disability, Exposure) focuses on identifying and managing life-threatening conditions.
  • Action: If trauma is the cause of hypovolemic shock, perform a primary and secondary survey to assess for all injuries. Document findings accurately. Follow trauma protocols and guidelines.
• Monitor Blood Loss in Post-Surgical Clients:
  • Rationale: Postoperative hemorrhage is a potential complication of surgery. Early detection and management of bleeding are essential.
  • Action: In post-surgical patients, closely monitor for signs of bleeding, including:
    • Wound drainage (amount and characteristics).
    • Dressing saturation.
    • Expanding hematoma.
    • Changes in vital signs.
    • Chest tube drainage (if applicable).
• Control External Bleeding:
  • Rationale: Direct pressure is the most effective initial method to control external bleeding.
  • Action: Apply firm, direct pressure to external bleeding sites using sterile dressings. Maintain pressure until bleeding is controlled.
• Consider Military Anti-Shock Trousers (MAST) or Pneumatic Anti-Shock Garments (PASGs) for Internal Bleeding (as ordered):
  • Rationale: MAST/PASG garments can provide counterpressure to the lower extremities and abdomen, helping to tamponade bleeding and increase blood pressure in patients with pelvic fractures or other sources of internal bleeding.
  • Action: If ordered, apply MAST/PASG garments according to manufacturer instructions. Monitor patient response and vital signs closely. These devices are typically used as a temporizing measure until definitive treatment can be provided.
• Calculate Fluid Replacement for Burn Patients (using Parkland formula or similar):
  • Rationale: Burn patients experience significant fluid losses due to increased capillary permeability and evaporative losses. Formulas like the Parkland formula help estimate fluid replacement needs in burn patients.
  • Action: Calculate fluid replacement needs for burn patients using the Parkland formula or another established burn resuscitation formula as ordered by the physician. Administer IV fluids accordingly.
• Initiate Cardiopulmonary Resuscitation (CPR) or Advanced Cardiac Life Support (ACLS) if Condition Deteriorates:
  • Rationale: Hypovolemic shock can progress to cardiac arrest if not treated effectively. Prompt initiation of CPR and ACLS may be life-saving.
  • Action: Be prepared to initiate CPR and ACLS according to established guidelines if the patient’s condition deteriorates and they become unresponsive or pulseless.
• Prepare for Return to Surgery if Bleeding is Secondary to Surgery:
  • Rationale: If postoperative bleeding is uncontrolled, surgical intervention may be necessary to identify and stop the source of bleeding.
  • Action: If bleeding is suspected to be surgical in origin and is not controlled by conservative measures, prepare the patient for a possible return to the operating room as directed by the physician.

5. Reducing Anxiety and Providing Emotional Support

The experience of hypovolemic shock can be frightening and anxiety-provoking for patients. Nursing interventions aim to reduce anxiety and provide emotional support.

Nursing Interventions:

• Assess Previous Coping Mechanisms:
  • Rationale: Understanding the patient’s usual coping mechanisms can help tailor interventions to reduce anxiety.
  • Action: Assess the patient’s usual coping strategies for stress and anxiety (if possible, or from family if patient is unable to communicate).
• Assess Level of Anxiety:
  • Rationale: Quantifying the patient’s anxiety level helps guide appropriate interventions.
  • Action: Assess the patient’s anxiety level using a standardized anxiety scale (if appropriate) or by observing for signs of anxiety (restlessness, agitation, verbalization of fear).
• Acknowledge Awareness of Client’s Anxiety:
  • Rationale: Acknowledging the patient’s feelings validates their experience and builds trust.
  • Action: Verbalize recognition of the patient’s anxiety and reassure them that their feelings are understood.
• Encourage Client to Verbalize Feelings:
  • Rationale: Allowing the patient to express their fears and concerns can help reduce anxiety.
  • Action: Create a safe and supportive environment for the patient to verbalize their feelings and concerns. Listen attentively and provide empathetic responses.
• Reduce Unnecessary External Stimuli:
  • Rationale: A quiet and calm environment can help reduce anxiety and promote rest.
  • Action: Minimize noise and unnecessary activity in the patient’s environment. Control lighting and temperature to promote comfort.
• Explain All Procedures and Treatments in Simple Terms:
  • Rationale: Providing clear and concise information about procedures and treatments can reduce anxiety related to the unknown.
  • Action: Explain all procedures and treatments to the patient in simple, understandable language before they are performed. Answer questions honestly and address concerns.
• Maintain a Confident and Assured Manner; Reassure Client of Continuous Monitoring:
  • Rationale: A confident and reassuring demeanor from the healthcare team can help instill trust and reduce patient anxiety. Assuring the patient of close monitoring provides a sense of security.
  • Action: Maintain a calm, confident, and professional demeanor. Reassure the patient and family that the patient is being closely monitored and that interventions will be implemented promptly as needed.

Evaluation

Patient outcomes are evaluated to determine the effectiveness of the nursing care plan.

Expected Outcomes:

• Patient maintains adequate fluid volume, as evidenced by:
  • Stable vital signs (blood pressure, heart rate within normal limits for patient).
  • Adequate urine output (>30 mL/hr in adults).
  • Improved skin turgor and moist mucous membranes.
  • Oriented to person, place, and time.
• Patient demonstrates understanding of causative factors of fluid volume deficit and preventive measures (if applicable).
• Patient exhibits reduced anxiety and expresses feelings of comfort and security.

Discharge and Home Care Guidelines

Discharge and home care instructions are crucial for ensuring continued recovery and preventing recurrence of hypovolemia.

• Follow-up Appointments: Emphasize the importance of attending all scheduled follow-up appointments with their healthcare provider to monitor their recovery and address any ongoing health concerns.
• Rest and Recovery: Advise the patient to prioritize rest and avoid strenuous activities during the initial recovery period. Gradually increase activity levels as tolerated and as advised by their healthcare provider.
• Hydration and Nutrition: Instruct the patient on maintaining adequate hydration by drinking sufficient fluids throughout the day. Discuss dietary recommendations to support healing and replenish any nutritional deficits.
• Wound Care (if applicable): If the hypovolemic shock was related to trauma or surgery, provide detailed instructions on wound care, including cleaning techniques, dressing changes, and signs of infection to watch for.
• Recognizing Warning Signs: Educate the patient and family about the warning signs and symptoms that may indicate a worsening condition or potential complications, such as dizziness, lightheadedness, decreased urine output, increased thirst, weakness, or confusion. Instruct them to seek immediate medical attention if any of these symptoms occur.
• Emotional Support: Acknowledge that hypovolemic shock can be a traumatic experience. Encourage the patient to seek emotional support from family, friends, or support groups to help cope with any anxiety, fear, or emotional distress.

Documentation Guidelines

Accurate and thorough documentation is essential for effective communication and continuity of care.

• Fluid Balance: Document the degree of fluid deficit upon admission, ongoing sources of fluid intake (oral, IV), and all fluid output (urine, emesis, drainage, stool). Record daily weights, presence of edema, urine specific gravity, and vital signs trends.
• Diagnostic Studies: Document the results of all diagnostic studies, including ABGs, electrolytes, coagulation studies, hematocrit, and hemodynamic monitoring parameters.
• Functional Status: Document the patient’s functional level and any limitations related to their condition.
• Resources and Support: Note any needed resources, adaptive devices, or community resources utilized.
• Plan of Care: Document the nursing care plan, including nursing diagnoses, goals, interventions, and expected outcomes.
• Patient Education: Record the teaching plan and the patient’s response to education.
• Response to Interventions: Document the patient’s responses to all nursing interventions and medical treatments, including fluid resuscitation, medication administration, and oxygen therapy.
• Progress Towards Outcomes: Evaluate and document the patient’s progress toward achieving desired outcomes.
• Plan Modifications: Document any modifications to the plan of care based on patient response and ongoing assessment.

Recommended Resources

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)

Alt text: Cover of “Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)” book, showcasing its title and authors.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care

Alt text: Cover of “Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care” book, emphasizing its comprehensive content.

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health

See also

Other recommended site resources for this nursing care plan:

Other care plans for hematologic and lymphatic system disorders.