Hypovolaemic Shock

Low complexity — Circulation

Back to overview

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