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UNIVERSITY OF THE ASSUMPTION

College of Nursing
City of San Fernando, Pampanga

SCIENTIA, VIRTUS et COMMUNITAS

R.L.E. - 106
ACUTE BIOLOGIC CRISIS

Hypovolemic Shock
SUBMITTED BY:

Angelika Flores Karen Tayag Princes Mae Tongol Chriscielle Ann Panlilio BSN 4A A2
SUBMITTED TO:

Mrs. Jesusa V. Gutierrez, R.N., M.A.N.

03 October 2011

Hypovolemic Shock
Definition:
>Most common type of shock >It is due to inadequate circulating blood volume resulting from hemorrhage with actual blood loss, burns with a loss of plasma proteins and fluid shifts, or dehydration with a loss of fluid volume. Hypovolemic shock occurs when there is reduction in intravascular volume of 15% to 25%. This would represent a loss of 750 to 1,300 mL of blood in a 70-kg (154-lb) person. Incidence:

There are no incidence statistics available for hypovolemic shock, as they are reported for the causative injuries or diseases rather than for the resultant physical state.
Risk Factors/Causes: External: Fluid Losses >Trauma >Surgery >Vomiting >Diarrhea >Diuresis(Diuretics) >Diabetes Insipidus (inadequate vasopressin) >Insensible fluid Losses ( Respiratory tract, hot environment) Internal: Fluid Shifts >Hemmorhage (e.g G.I bleeding, blood coagulation disorders, ruptured esophageal reflux, loss of 500 to 1500 ml of blood, shock fully develops if a previously healthy clients loses about one third of the normal circulating blood volume of 5 L) >Burns (large partial thickness or full thickness burns) >Ascites >Peritonitis >Dehydation >Severe crush injuries >Starvation >Conditions causing plasma fluids to accumulate in the abdominal cavity (e.g pancreatitis and bowel obstruction)

Pathophysiology Internal or External Blood Loss Decrease intravascular volume Diminished venous return Decrease preload Decrease stroke volume Decrease cardiac output Decrease perfussion Decrease oxygen and nutrients delivery to cells Hypovolemic Shock Signs and Symptoms INITIAL STAGE (approx. 750 to 1500 ml of blood loss) Blood pressure: normal to slightly decreased Pulse: slightly increased from baseline (>100) Respirations:normal (baseline) Skin: cool,pale (in periphery),moist Mental status: alert and oriented Urine output:slight decrease Other: thirst,decreased capillary refill time COMPENSATORY AND PROGRESSIVE STAGE ( approx. 1500 to 2000 ml of blood loss) Blood:pressure:hypotension Pulse:rapid,thread (>120) Respirations:increased (30 to40cpm) Skin:cool,pale(includes trunk);poor turgor with fluid loss,edematous with fluid shift Mental status:restless,anxios,confused,or agitated

4 Urine output:oliguria(less than 30 ml/h) Other:marked thirst,acidosis,hyperkalemia,decreased capillary refill time,decrease or absent peripheral pulses

IRREVERSIBLE STAGE (approx. 2000 or more blood loss) Blood pressure: severe hypotension (often,systolic pressure is below 80 mmhg) Pulse:very rapid,weak Respirations:rapid ,shallow,crackles and wheezes Skin:cool,pale mottled with cyanosis Mental status:disoriented,lethargic,comatose Urine output:unuria Other:loss of reflexes,decreased or absent peripheral pulses Nursing Diagnosis Ineffective breathing pattern related to rapid respirations and progression of septic shock Decreased Cardiac Output related to altered stroke volume, altered preload (e.g., decreased venous return ) Ineffective Tissue Perfussion related to progression of shock with decreased cardiac output, hypotension, and massive vasodilation Deficient fluid volume related to vomiting, diarrhea, high fever, and shift of intravascular volume to interstitial spaces Anxiety related to major trauma and multiple injuries.

Medical Management Treatment of underlying cause Fluid Replacement -most effective treatment Crystalloid Solutions- contain dextrose solutions or electrolytes dissolve in water; they are either isotonic or hypotonic. Isotonic Solutions include Normal Saline (0.9%), lactated Ringers solutions, and Ringers solution. Hypotonic solutions include one-half normal saline (0.45%) and 5% dextrose in water (D5W). Colloid Solutions- contain substances that should not diffuse through capillary walls. Hence, they tend to remain in the vascular system and increase the osmotic pressure of the serum, causing fluid to move into the vascular compartment from the interstitial space. As a result, plasma volume expands. The solutions are also given to replace lost serum protein. Examples are 5% albumin, 25% albumin, hetastarch, plasma protein fraction, and dextran.

5 >Colloid products reduce platelet adhesiveness and have been associated with reductions in blood coagulations. Clients prothrombin time (PT), platelet count and activated partial thromboplastin time (APTT) should be monitored. Normal values: PT= 10-15 sec. Platelet= 150, 000-400,000 APTT= <35 sec. Blood Transfusion -most effective treatment also, the goal of blood administration is to keep the hematocrit at 30% to 35% and the haemoglobin level between 12.5 to 14.5 g/100 mL. Fresh whole blood Stored whole blood Packed RBCs Platelet concentrate Fresh frozen plasma Cryoprecipitate Oxygen Therapy All clients in shock (even those with adequate respirations) should receive oxygen therapy (usually by mask or nasal cannula) to maintain the PaO2 at greater than 80 mmHg during the first 4 to 6 hours of care. Medications Vasoactive Drugs (drugs causing vasoconstriction or vasodilation) and inotrophic drugs (drugs improving cardiac contractility). Diuretics to increase urine output after fluid replacement has been initiated Sodium bicarbonate to treat acidosis Calcium to replace lost as a result of blood transfusions Antiarrhytmias to stabilize heart rhythm A cardiac glycoside such as digitalis to treat cardiac failure Morphine to dilate veins and decrease anxiety Application of pneumatic anti shock garment

Nursing Interventions Assess ABCs (Airway, Breathing, Circulation) Assess mental status and level of consciousness (Restlessness and anxiety are common early in shock). Proper positioning- Place in supine position with legs elevated to 20, trunk flat and head and shoulders elevated higher than the chest about 10. Turn the victims head to one side if neck injury is not suspected

6 Speak slowly and calmly, using short sentences. Eliminate all non essential activities Administer blood and blood components, fluids, and oxygen safely as ordered Administer medications as ordered Keep the person warm and comfortable Provide quiet and comfortable environment to decrease 02 demand The vital signs and cardiac rhythym are monitored frequently ro ensure the safety of the client Monitor and record fluid status- includes daily assessment of weight, fluid intake by all routes, measurable fluid loss (urine, vomitus, wound drainage, gastric drainage, and chest tube drainage). Monitor urine output hourly, reporting any output of <30 ml/ hr. Explain any procedures and provide comfort measures (oral care, skin care, turing and positioning). Monitor 02 saturation, ABG result, blood counts, clotting times and platelet counts. Monitor cardiopulmonary function by assessing the bp, rate and depth of respirations, lungs sounds, pulse oximeter, peripheral pulses, jugular vein distention, CVP measurements. Observe skin color, temperature, moisture and check capillary refill Remain with client during procedures. Maintain bed rest Provide emotional support

References: LeMone and Burke, Principles of Medical-Surgical Nursing Critical Thinking in Client Care 4th edition. Pearson Prentice Hall 2007 Sparks and Taylors, Nursing Diagnosis Reference Manual 6th edition. Lippincott Williams & Wilkins 2005

CURRENT TRENDS The trendelenburg position or T-position is no longer recommended, because it causes the abdominal organs to press against the diaphragm (limiting respirations), decreases filling of the coronary arteries, and initiates aortic and carotid sinus reflexes.
Source: Principles of Medical Surgical Nursing: Critical Thinking in Client Care 4th Edition, Volume 1 Priscilla LeMone and Karen Burke Nanoparticles Increase Survival After Blood Loss, Study Suggests ScienceDaily (Feb. 22, 2011) In an advance that could improve battlefield and trauma care, scientists at Albert Einstein College of Medicine of Yeshiva University have used tiny particles called nanoparticles to improve survival after lifethreatening blood loss. Nanoparticles containing nitric oxide (NO) were infused into the bloodstream of hamsters, where they helped maintain blood circulation and protect vital organs. The research was reported in the February 21 online edition of the journal Resuscitation. "The new nanomedicine was developed to address the need for better field treatments for massive human blood loss, which can cause hypovolemic shock and cardiovascular collapse or hemorrhagic shock. This potentially fatal condition is best treated with infusions of refrigerated blood and other fluids. But such treatments are limited to emergency rooms or trauma centers.

8 "It is highly impractical to pack these supplies for use in rural emergencies, masscasualty disasters or on the battlefield," said coauthor Joel Friedman, M.D., Ph.D., professor of physiology & medicine and of medicine and the Young Men's Division Chair in Physiology at Einstein. "Our nanoparticle therapy may offer the potential for saving lives in those situations. It's lightweight and compact and doesn't require refrigeration." The new therapy counters hypovolemic and hemorrhagic shock by increasing the body's levels of NO gas, which, among other physiological functions, relaxes blood vessels and regulates blood pressure. The gas was encased in microscopic-sized particles that were specially designed by the Einstein team. (NO is so short-lived that delivering it in therapeutic amounts requires a method of sustained release.) The therapy is created by adding the NO-containing nanoparticles to saline solution, which was then infused into the animals. Once in the body, the nanoparticles gradually release a sustained dose of NO to tissues. The nanomedicine was successfully tested in hamsters that had lost half their blood volume. "Animals given the nanoparticles exhibited better cardiac stability, stronger blood flow to tissues and other measures of hypovolemic and hemorrhagic shock recovery compared to controls receiving saline solution minus the nanoparticles," reported Dr. Friedman. Source: http://www.sciencedaily.com/releases/2011/02/110222151346.htm Journal Source: Parimala Nachuraju, Adam J. Friedman, Joel M. Friedman, Pedro Cabrales. Exogenous nitric oxide prevents cardiovascular collapse during hemorrhagic shock.Resuscitation, 2011.

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