Hypovolemia Nursing Care Plans Diagnosis and InterventionsHypovolemia NCLEX Review and Nursing Care Plans Show
Fluids make up between 50 and 60 percent of the body. When a person has hypovolemia, they lose more than 15% of the total amount of fluid in their circulatory system. Hypovolemia becomes life-threatening when the body does not have enough fluid (blood) volume circulating in the system. The term hypovolemia refers to two different health conditions:
The prognosis for patients diagnosed with hypovolemia differs. Each instance is dependent on identifying and addressing the source of the blood or fluid loss. When hypovolemia is diagnosed and treated early, the prognosis is usually favorable. When therapy starts to replace the fluid lost in the body, symptoms will reduce and eventually disappear as the fluids resume average level. However, untreated instances or delayed treatment can have a fatal effect, including irreversible organ damage or death. Stages of HypovolemiaStage 1 The initial stage of hypovolemia is defined as a blood volume loss of less than 15%, or 750 milliliters (ml). This stage’s symptoms include:
Stage 2 Stage 2 is characterized by 15–30% of blood volume or 750–1,500 ml loss. This hypovolemia stage’s symptoms usually involve:
Stage 3 This stage indicates 30–40% blood loss or 1,500–2,000 ml. This stage’s indications entail:
Stage 4 Perhaps the most severe stage indicates that the patient has lost more than 40% of his blood volume or more than 2,000 ml. The fourth hypovolemia stage’s symptoms involve:
Signs and Symptoms of HypovolemiaThe following are some of the most typical early signs of hypovolemia:
Hypovolemia that leads to hypovolemic shock is a potentially fatal condition. Refer the patient to the physician at once if the patient is experiencing any of the following severe symptoms of hypovolemic shock:
Causes of HypovolemiaHypovolemia can be caused by conditions that cause blood or bodily fluid loss, insufficient fluid consumption, and dehydration. Volume depletion can be caused by a variety of factors, including:
Many illnesses that induce hypovolemia are severe or life-threatening and necessitate immediate medical attention. These are some examples:
Risk Factors to HypovolemiaRisk factors of hypovolemia that involve bleeding include:
Among the risk factors related to hypovolemia that do not involve bleeding are:
Complications of HypovolemiaComplications of uncontrolled hypovolemia can be severe or even fatal when it already causes hypovolemic shock. Without prompt treatment, hypovolemia complications may include:
Treatment for HypovolemiaSince hypovolemia can promptly develop into hypovolemic shock and induce organ damage, it is crucial to treat hypovolemia as soon as it appears. At this stage, treatment may include:
Prevention of HypovolemiaThe following measures must be taken to prevent hypovolemia or hypovolemic shock:
Hypovolemia Nursing DiagnosisHypovolemia Nursing Care Plan 1Anxiety Nursing Diagnosis: Anxiety related to modifications in medical status, fear of dying and unfamiliar surroundings secondary to hypovolemia as evidenced by uncertainty, difficulties concentrating, increased alertness, increased inquiry, and sympathetic stimulation. Desired Outcomes:
Hypovolemia Nursing Care Plan 2Decreased Cardiac Output Nursing Diagnosis: Decreased Cardiac Output related to heart rate and rhythm changes, reduced ventricular filling (preload) secondary to hypovolemia as evidenced by abnormal arterial blood gasses (ABGs), cerebral hypoxia and acidosis, capillary refill time greater than 3 seconds, cardiac arrhythmias, altered level of consciousness, cold, clammy skin, reduced urine output (less than 30 ml per hour), significantly reduced blood pressure, pulse pressure, and peripheral pulses and palpitations. Desired Outcome: The patient will maintain appropriate cardiac output as shown by strong peripheral pulses, systolic blood pressure within 20 mm Hg of baseline, heart rate 60 to 100 beats per minute with a steady rhythm, urine output 30 ml/hr or higher, dry and warm skin, and normal state of consciousness.
Hypovolemia Nursing Care Plan 3Ineffective Tissue Perfusion Nursing Diagnosis: Ineffective Tissue Perfusion related to reduced stroke volume, reduced preload, impaired venous return, and significant loss of blood secondary to hypovolemia as evidenced by changed mental status, cold, clammy skin, pallid complexion, cyanosis, prolonged capillary refill, vertigo, deep respirations, and a feeble, thready pulse. Desired Outcome: The patient will retain optimum tissue perfusion to vital organs as indicated by dry and warm skin, continuous and steady peripheral pulses, vital signs within the patient’s accepted value, balanced input and output, absence of inflammation, normal ABG levels, 15/15 GCS level of consciousness, and lack of chest discomfort.
Hypovolemia Nursing Care Plan 4Deficient Fluid Volume Nursing Diagnosis: Deficient Fluid Volume related to active fluid volume loss as a result of unusual bleeding, diarrhea, increased urination, or aberrant drainage, internal fluid changes, insufficient fluid consumption or severe dehydration, regulatory system failure, or trauma secondary to hypovolemia as evidenced by capillary refill time of more than 3 seconds, alterations in level of consciousness, cold, clammy skin, reduced skin turgor, vertigo, dry mucous membranes, extreme thirst, pulse pressure constriction, orthostatic hypotension, palpitations, and urinary output that can range between average (>30ml/hr) and as low as 20 ml/hr. Desired Outcome: The patient will be normovolemic, and his or her heart rate is 60 to 100 beats per minute, systolic blood pressure is greater than or equal to 90 mm Hg, there is no orthostasis, urine output is more than 30ml/hr, and skin turgor is normal.
Hypovolemia Nursing Care Plan 5Fatigue Nursing Diagnosis: Fatigue related to blood loss secondary to hypovolemia as evidenced by accelerated heartbeat, shallow respiration, and a sense of lethargy and exhaustion. Desired Outcomes:
Nursing ReferencesAckley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon Disclaimer:Please follow your facilities guidelines, policies, and procedures. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. What are the interventions for hypovolemic shock?Three goals exist in the emergency department treatment of the patient with hypovolemic shock as follows: (1) maximize oxygen delivery—completed by ensuring adequacy of ventilation, increasing oxygen saturation of the blood, and restoring blood flow, (2) control further blood loss, and (3) fluid resuscitation.
What is the first step you should take for a patient with hypovolemic shock?Hypovolemic Shock Treatment
The first step is to get you to the emergency room as quickly as possible. Along the way, someone should try to stop any visible bleeding. Your medical team will try to: Get as much oxygen as possible to all parts of your body.
What are the possible nursing intervention for a patient presented with shock?The nursing role in managing the patient with shock
Common interventions include adequate oxygen, fluid and/or drug therapy. In all cases the nurse needs to provide a safe environment for the patient who may be at risk due to a reducing level of consciousness and deteriorating vital signs.
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