Hypovolaemic Shock

Low complexity — Circulation

Goals

  1. Recognise the symptoms of hypovolaemic shock and apply nursing interventions accordingly.
  2. Recognise and describe the compensatory mechanisms in hypovolaemic shock.
  3. Provide treatment recommendations.

Anamnese

  • Name: Mr Slegers
  • Age: 53 years
  • Family: Cohabiting
  • Occupation: Nurse
  • Cultural: Not known

AMPLE

A: Unknown

M: Acetylsalicylic acid, clopidogrel and captopril

P: Hypertension and myocardial infarction (6 months ago)

L: Bread meal 2 hours ago

E: Abdominal complaints and diarrhoea

SBAR

S: Mr Slegers is admitted to your ward for observation of abdominal complaints and persistent diarrhoea. He reports feeling very weak and dizzy. He also says he is nauseous.

B: Mr Slegers is 53 years old. His history includes hypertension and a myocardial infarction (6 months ago). He uses acetylsalicylic acid, clopidogrel and captopril.

A: See ABCDE

R: Please assess the patient using ABCDE and apply interventions where necessary.

Situation at the start of scenario

A: Clear, appears weakened.

B: RR 22 breaths/min, symmetrical thoracic excursions, normal work of breathing, not using accessory breathing muscles, normal jugular veins, normal breath sounds, saturation 95%.

C: Pale colour, CRT 3 sec, HR 104 bpm, weak regular pulse, peripherally cold and clammy, BP 97/53 mmHg.

D: Alert on AVPU, fatigued, glucose 6.4, pupils PEARL.

E: Temp 36.8°C, pale skin, no active blood loss visible. No oedema in legs. Urine output: spontaneous 200 ml 5 hours ago.

Situation at the end of scenario

A: Clear, reduced consciousness, closing eyes.

B: RR 25 breaths/min, symmetrical thoracic excursions, normal work of breathing, not using accessory breathing muscles, normal jugular veins, normal breath sounds, saturation 93%.

C: Increasingly pale colour, CRT 5 sec, HR 124 bpm, weak regular pulse, peripherally cold and clammy, BP 78/39 mmHg.

D: Voice on AVPU, glucose 6.7, pupils PEARL.

E: Temp 36.8°C, pale skin, active blood loss visible between legs (rectal). No oedema in legs.

Recommendations

  • Administer blood products