Primary Nursing Diagnosis

Fluid volume deficit related to active bleeding or fluid loss

508 Hypovolemic/Hemorrhagic Shock

OUTCOMES. Fluid balance; Circulation status; Cardiac pump effectiveness; Hydration

INTERVENTIONS. Bleeding reduction; Fluid resuscitation; Blood product administration; Intravenous therapy; Circulatory care; Shock management

H PLANNING AND IMPLEMENTATION Collaborative

The initial care of the patient with hypovolemic shock follows the ABCs of resuscitation. Measures to ensure adequate oxygenation and tissue perfusion include establishing an effective airway and a supplemental oxygen source, controlling the source of blood loss, and replacing intravascular volume. The American College of Surgeons recommends crystalloid fluids such as normal saline solution or lactated Ringer's solution for stages I and II and crystalloids plus blood products for stages III and IV. Although vasopressors, such as norepinephrine or dopamine, do increase blood pressure in the setting of hypovolemic shock, they should never be started if there is insufficient intravascular fluid or if tissues remain underperfused despite an adequate blood pressure.

The objective of fluid replacement is to provide for adequate cardiac output to perfuse the tissues. Generally, any fluid transiently improves perfusion, but only red blood cells (RBCs) can carry enough oxygen to maintain cellular function. Three milliliters of crystalloid solutions should be infused for every 1 mL of blood loss. It is currently recommended to use caution in replacing fluids after trauma because the low flow state may protect the patient from further bleeding until the traumatic injury is repaired. After repair, fluid resuscitation can be used aggressively. RBCs or whole blood should be considered when fluid resuscitation with crystalloids is not successful. RBCs are preferred because they contain an increased percentage of hemoglobin per volume. Type-specific blood is preferred, although O-negative can be used if type-specific blood is not immediately available.

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