quickLESSON Description/Etiology

Hypovolemic shock is a potentially fatal medical emergency that occurs when a reduction in intravascular fluid
about... volume causes the heart to be unable to supply enough blood to the body. Causes of hypovolemic shock include severe
fluid or blood loss (e.g., in traumatic blood loss) and severe internal fluid shifts (e.g., as occur in patients with severe
dehydration, edema, or ascites).
Shock,
Potential complications of hypovolemic shock are multiple organ failure, disseminated intravascular coagulation
Hypovolemic (DIC), acute lung injury (ALI), acute respiratory distress syndrome (ARDS), kidney and brain damage, and death.
The prognosis varies depending on the amount of fluid or blood loss, the speed at which the loss occurs, and the
promptness of treatment. Rapid volume resuscitation with I.V. fluids is the most important intervention to help restore
adequate organ perfusion. Other treatment includes applying pressure to control bleeding, infusing blood or blood
products, and administering vasopressors and inotropics to treat hypotension, antisecretory agents to maintain blood
fluid volume, and sodium bicarbonate to treat acidosis. Surgery may be necessary to control bleeding in some patients.

Facts and Figures

Although its incidence is unknown, hypovolemic shock is the most common form of shock, particularly in children.
A reduction of intravascular volume of 15–30%—the equivalent of 750–1,500 mL of blood from a person
weighing 70 kg (154 lb)—can result in hypovolemic shock.

Risk Factors
Risk factors for hypovolemic shock resulting from blood loss include intra- and postpartum complications (e.g.,
ectopic pregnancy, placental abruption, placenta previa), trauma, pelvic and femoral fracture, liver injury, ruptured
abdominal or thoracic aortic aneurysm, gastrointestinal (GI) tract bleeding, and surgery. Fluid loss through vomiting,
diarrhea, diuresis, and diabetes insipidus increases risk of hypovolemic shock. Internal fluid shifts leading to
hypovolemic shock can result from severe burns, ascites, peritonitis, and dehydration. Older adults are at risk for more
severe hypovolemic shock and for developing complications such as myocardial infarction and stroke.
ICD-9
785.59
Signs and Symptoms/Clinical Presentation
ICD-10 Patients may present with tachypnea, tachycardia, cool and clammy skin, weakness, pallor, weak peripheral pulses,
R57.1 sluggish capillary refill, hypotension, mottled extremities, dry mucous membranes, bloody vomit or stools, and
significant changes in mental status (including confusion, anxiety, agitation, restlessness, delirium), end-organ
Authors damage, and coma.
Renee Matteucci, MPH
Tanja Schub, BS Assessment
44 Patient History
Reviewers
Leonard L. Buckley, MD
•• Ask family members if the patient has received beta blockers or calcium channel blockers or has a
Cinahl Information Systems pacemaker, any of which can cause a patient with hypovolemic shock to present without tachycardia,
Glendale, California delaying diagnosis and treatment
44 Physical Findings of Particular Interest
Eliza Schub, BSN, RN
•• Physical examination may reveal tachypnea; orthostatic or supine hypotension; decreased mean arterial
Cinahl Information Systems
pressure (MAP; < 60 mm Hg); cool, moist, cyanotic, pale skin; decreased breath sounds and/or muffled
Glendale, California
heart sounds; rapid, thready, or faint pulse; and a tender, enlarged abdomen
Darlene A. Strayer, RN, MBA 44 Laboratory Tests That May Be Ordered
Cinahl Information Systems •• Complete blood count (CBC) may show decreased Hgb, Hct, and platelets
Glendale, California •• Blood urea nitrogen (BUN) may be elevated, suggesting kidney dysfunction
•• Creatinine levels and serum lactate may be elevated
Nursing Practice Council
Glendale Adventist Medical Center
•• Serum electrolyte panel may show abnormalities
Glendale, California •• Urinalysis (UA) may show hematuria; urinary output may be < 400 ml/day or absent, and urine specific
gravity may be increased
Editor •• Pulse oximetry may show decreased oxygen saturation
Diane Pravikoff, RN, PhD, FAAN
•• Arterial blood gases (ABGs) may identify metabolic (lactic) acidosis
Cinahl Information Systems
•• Coagulation studies may show prolonged PT and prolonged aPTT
•• Liver function tests may show elevated liver enzymes, suggesting liver damage
•• Pregnancy testing may be ordered for women of childbearing age if complications of pregnancy are
February 4, 2011 suspected as a cause of hypovolemic shock

Published by Cinahl Information Systems. Copyright©2011, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any
form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing
from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a
general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
 44 Other Diagnostic Tests/Studies
•• X-rays or computed tomography (CT) scan of the chest, abdomen, or pelvis may show thoracic or abdominal aortic dissection as a cause of hypovolemic shock
•• X-ray of femur may show a fracture as a cause of hypovolemic shock
•• GI endoscopy and gastric lavage may be ordered to assess for a source of GI tract bleeding
•• Echocardiogram and electrocardiogram may identify cardiac abnormalities
•• Positive tilt testing and positive orthostatic vital sign testing could be indicative of volume depletion and impending hypovolemic shock
•• Swan-Ganz catheterization may show abnormalities in cardiac blood flow and function; results of decreased central venous and pulmonary artery wedge
pressure usually indicate hypovolemic shock

Treatment Goals
44 Promote Resuscitation and Restoration of Fluid Volume
•• Check for airway patency and evaluate respiratory status. Provide supplemental oxygen, as prescribed, and assist with intubation and maintain
mechanical ventilation, if ordered
•• Control bleeding by applying direct pressure or pressure dressings, or using pneumatic antishock trousers per clinician order or facility protocols
•• Elevate the patient’s legs about 12 inches to promote return of venous blood; if patient is pregnant, place on left side to improve circulation. Do not
elevate the legs if head, back, neck, or leg injuries are present
•• Infuse prescribed I.V. crystalloids (e.g., normal saline, Ringer’s lactate solution) or colloids (e.g., dextran 70, albumin) to maintain electrolyte balance
and restore circulating fluids; do not give fluids by mouth
•• Transfuse prescribed blood products (e.g., whole blood plasma products or packed red blood cells), including fresh-frozen plasma if ordered for a patient
with severe burn injury
•• Follow facility pre- and postsurgical protocols if patient becomes a surgical candidate for resolution of hemorrhage; reinforce pre- and postsurgical
education and ensure completion of facility informed consent documents
–– Postsurgically, monitor for pain and surgical complications; provide analgesia and postsurgical wound care, as ordered
44 Maintain Optimum Physiologic Status and Reduce Risk of Complications
•• Administer prescribed vasopressors (e.g., dopamine, vasopressin, epinephrine, or norepinephrine) or inotropics (e.g., dopamine, dobutamine, inamrinone, or
milrinone) to treat hypotension; antisecretory agents (e.g., somatostatin or octreotide) to maintain blood fluid volume; and sodium bicarbonate to treat acidosis
–– Monitor treatment efficacy and for adverse effects; consult a drug information resource for a complete listing of adverse effects
–– Monitor for signs of complications, including respiratory distress, organ failure, DIC, transfusion reactions, and secondary infections
•• Continuously monitor vital signs and pulse oximetry, cardiac output, intake and output, central venous and pulmonary artery wedge pressure, and skin
color; review laboratory test results
•• Provide parenteral nutritional support, as ordered, and maintain urinary catheterization
44 Promote Emotional Well-Being and Educate
•• Assess patient and family member anxiety level and coping ability; provide emotional support and communicate clearly and calmly during the diagnostic
process and while treatment is given to reduce stress
•• Educate and encourage discussion of hypovolemic shock pathophysiology, potential complications, treatment risks and benefits, and individualized prognosis

Food for Thought

44 Controversy exists regarding the relative effectiveness of colloids versus crystalloids in the resuscitation of critically ill patients. A recent systematic review
concluded that evidence supporting the superiority of colloids is lacking and, because crystalloids are less expensive, the use of colloids cannot be justified
(Perel et al., 2007)

Red Flags
44 Closely monitor for tachycardia in patients receiving vasopressor or inotropic therapy

What Do I Need to Tell the Patient/Patient’s Family?

44 Educate the family and patient on how to recognize signs and symptoms of complications of hypovolemic shock and to seek immediate medical attention if
these develop

References
•• Ecklund, M. M., & Ecklund, C. R. (2007). How to recognize and respond to hypovolemic shock: What to do when your patient’s fluid volume bottoms out. American Nurse Today, 2(4), 28-31.
•• Kolecki, P., & Menckhoff, C. R. (2010). Shock, hypovolemic. emedicine from WebMD. Retrieved December 1, 2010, from http://emedicine.medscape.com/article/760145-overview
•• Makic, M. B. F. (2010). Shock and multiple organ dysfunction syndrome. In S. C. Smeltzer, B. G. Bare, J. L. Hinkle, & K. H. Cheever (Eds.), Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed., pp. 322-325).
Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
•• Perel, P., & Roberts, I. (2007). Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database of Systematic Reviews, (4), CD000567.
•• van der Heijden, M., Verheij, J., van Nieuw Amerongen, G. P., & Groeneveld, A. B. (2009). Crystalloid or colloid fluid loading and pulmonary permeability, edema, and injury in septic and nonseptic critically ill patients with hypovolemia.
Critical Care Medicine, 37(4), 1275-1281.
•• Yager, P, & Noviski, N. (2010). Shock. Pediatrics in Review, 31(8), 311-319.