hey everyone its ears registered nurse Orion Colin today we're going to continue our series on shock by talking about hypovolemic shock and as always after you watch this YouTube video you can access the free quiz that will test you on this condition so let's get started hypovolemic shock occurs when there is low fluid volume in the blood hence where the named hypovolemic comes from hypo means low vol means volume and emic means blood so we have low blood volume and we're specifically talking about the blood volume in the intravascular space and this space contains the volume of blood in a person's circulatory system so if we deplete that volume of blood in a person's circulatory system what does that leave that heart to pump throughout the body not very much so what will happen the amount of blood that this heart pumps per minute is going to decrease and we're talking about cardiac output so if we decrease cardiac output the amount of blood that is going to the cells tissues and organs is going to dramatically decrease too so those cells are going to be deprived of oxygen and when we do that cells start to die and then we start seeing signs and symptoms of shock now a person needs to lose about 15% or more of their volume for signs and symptoms of shock to occur now in the average human adult they have about 5 liters of blood so a person loses 1 liter of that 5 liters they've lost 20% of their volume so whenever they lose that much they're gonna start showing signs and symptoms of shock now let's talk about the causes of hypovolemic shock so why can lead to a loss of fluid in the intravascular system well any conditions that really cause fluid to leave the body externally like there's some type of major injury so that person is just outwardly bleeding or there is some type of inside shift of fluid leaving that intravascular space so let's talk about the two types of hype Lehman shock first type is called relative hypovolemic shock and this is where you have an inside fluid shift from that intravascular system and this tends to be a little bit more concealed than the absolute type which we're going to talk about next you're not gonna see just bright red blood leaving the body like how you could and absolute and you know that that patients losing fluid there's gonna be a little bit more concealed so this is where fluids or blood is collecting or leaking inside the body and this can occur with internal bleeding or where you have third spacing a fluid like with severe burns and this occurs due to increased capillary permeability and we talked in depth about this in our Burns video in addition long bone fractures they're very vascular can cause a lot of fluid loss in addition damage to organs like in acute pancreatitis you can see this when a patient develops colon or Turner sign and colon sign is where you have severe bruising around the belly button and Turner sign is where you have severe bruising on the flanks and that can indicate that the patient is having internal hemorrhage and that occurs with acute pancreatitis and another thing is like massive vasodilation that occurs in sepsis the next type is absolute hypovolemic shock and this is where you have an outside fluid shift from the intravascular system and this is more noticeable compared to the relative type and this is where fluid is leaving the body externally you can see it and this can occur with massive bleeding that's been experienced due to blood loss with surgery or some type of injury excessive fluid loss and this can be through the oral route with vomiting or the GU route urination or GI diarrhea or sweating with your skin and many times whenever that occurs it's being caused by some type of disease process the patient's really sick so they're just throwing up a lot or some type of endocrine disorder now let's talk about the pathophysiology of bloomix off and tie in the signs and symptoms associated with this condition okay let's say we have a patient who's in hypovolemic shock and it's due to like either a relative or an absolute cause vote regardless what's happened is that their intravascular system their circulatory system has been depleted of fluid volume so what's going to happen is that you're going to get a decrease amount of flu evolve as returning to this heart to be pumped so we have a low venous return to the heart that intravascular system has been depleted of it so there's really nothing to drain back now whenever that happens it's going to affect cardiac preload now what is preload this is the amount that these ventricles stretch at the end of diastole at the end of that filling face of the heart so it's the end diastolic volume well we don't have a lot of fluid volume draining back to that heart those ventricles really aren't going to stretch they don't have to stretch because the fluid volunteer now cardiac preload is a determining factor in stroke volume and stroke volume is the amount of blood that this ventricle pumps each with each beat which should be anywhere between 50 to 100 MLS well when our stroke volume falls it decreases cardiac output because remember cardiac output is heart rate times stroke volume and cardiac output is the amount that this heart pumps per minute and it should be anywhere between eight to four liters but if we have a decrease in stroke volume that's going to decrease our cardiac output now when we get a decreased cardiac output this is going to decrease the mail of blood that's flowing to our organs and our tissues specifically to those cells so we're going to get decreased tissue perfusion and what's that magical substance in the blood that cells love oxygen so when you decrease the amount of oxygen that is flowing to these cells they're going to start struggling they attempt to try to save themselves at first by switching the way they metabolise from aerobic to anaerobic but the problem with that is that you're going to get the built-up the build-up of lactic acid which is going to throw off at our pH of our blood entering into acidotic conditions and then the body's going to try to compensate and it's going to activate the sympathetic nervous system and the NGO Tinson the renin system it's going to be shunting blood all in an attempt to help save the body save those organs now the signs and symptoms of hypovolemic shock are affected by the percentage of fluid volume loss that patient has experienced so hypovolemic shock can be divided into four classes or four stages and to help you remember those stages / classes remember the criteria numbers for each percentage loss so the numbers you want to remember are 15 that's class 1 15 to 30 that's class 2 30 to 40 that's class 3 and then the last class last stage is 40% ok so class 1 this is where the patient has lost less than 15% of their fluid volume and that's about 7 to 750 ml's in an adult now during this class / stage the body can deal with this it can come and say enough to maintain cardiac output now because of that your patients really going to be asymptomatic with a fluid volume loss of less than this because remember beginning the lecture I said that patients who have 15% or more are gonna start showing those signs and symptoms of hypovolemic shock because the body really can't compensate for that and it has to turn on its sympathetic nervous system and all of that so in this class last stage how do you expect our heart rate to be it's going to be less than 100 they're not gonna have tachycardia so it's going to be within normal limits maybe a little bit on the high end maybe 80s or 90s blood pressure it's going to be within normal limits our body is maintaining our cardiac output respirations within normal limits we're not having any issues with decreased oxygen just yet because our body can deal with this blood loss Mental Status they're probably going to be normal they may have lit they may be a little anxious but nothing major their skin is going to be warm to the touch their capillary refill is going to be less than two seconds whenever we check that and their urinary output is going to be greater than 30 CC's an hour so kidneys are doing great that's where we want them next we have class two and this is where we've lost 15 to 30 percent of fluid volume so anywhere between 750 to 1,500 ml's in an adult so with this because we've lost more fluid volume than compared to here our cardiac output is decrease the body cannot maintain its own cardiac output with this amount of fluid volume loss so it has to activate that sympathetic nervous system the body's receptors in the body since hey we can't do this so those baroreceptors activate it and that's in turn going to activate our renin-angiotensin system you're gonna get shunting of blood away from non vital organs so in a nutshell what you're gonna have is vasoconstriction from those catecholamines from angiotensin ii and this is going to constrict vessels and this is going to increase venous return to the heart we're just going to increase our cardiac preload stroke volume cardiac output and increase our blood pressure so we're going to be maintaining tissue perfusion making ourselves happy giving them oxygen also we're going to be increasing blood volume through some hormones under the influence of angiotensin ii so we're gonna have a th-the antidiuretic hormone on board that's going to cause us to retain water and aldosterone which is going to help us conserve sodium and water and all that and hope of increasing blood volume volume in the blood which is going to end crease the venous return to the heart preload stroke volume and cardiac output so our signs and symptoms are going to really be around what's going on because our body here is compensating with its built in system so how do we expect our heart rate to be it's going to be increased because of the fact of the catecholamines on the heart so we're gonna have some tachycardia going on it'll be mild it's going to be less than 120 so less than 120 our blood pressure is going to be decreased from where that patient normally is but they're not gonna be hypotensive just yet because the system is working to maintain our cardiac output but it'll be slightly decreased our respiratory array is going to be increased a little bit just mildly from everything that's going on we've dropped in our oxygen so the body's increasing respiratory to take in some more oxygen to help increase that level urinary output well what's going on with her ADH and aldosterone it's causing us to keep water so our urinary output is going to decrease so instead of being the normal where we want it 30 emails per hours it's probably going to be between 20 to 30 so it's going to decrease skin now we're diverting blood away from non vital organs the skin is one of them so instead of our skin be warm and flushed it's gonna be cool and clammy from where blood is being diverted capillary refill the same concept there instead of being less than two seconds it's going to be increased so greater than two seconds peripheral pulses because we're shifting blood away from those extremities they're going to start becoming diminished and how we fill them and Mental Status instead of just having being normal or maybe just a little bit anxious they're gonna start to have some mild anxiety going on next is class three and this is where the patient has lost 30 to 40 percent of their fluid volume and this is anywhere between 1,500 to 2000 MLS of fluid now because it is this much the body can no longer compensate so compensatory mechanisms are going to fell they're not going to be able to do it and our cardiac output is just really it is fel because they've lost so much blood in that circulatory system that the heart doesn't really have much to pump out maintain perfusion so you're gonna see those cells that make up those organs and tissues you're gonna see malfunctioning of our body system so we're ending up having failure so our heart rate is going to be significantly high it's going to be greater than 120 we're gonna have tachycardic tachycardia their blood pressure they're gonna have severe hypotension because we don't have the body being able to maintain blood pressure so we're gonna have some hypotension going on respiratory rate is going to be majorly increased their hitting respiratory failure territory so they need mechanical ventilation intubation possibly to help assist them urinary output is going to be low Oh Gloria so it's definitely gonna be less than 30 CC's an hour we're getting in the renal failure territory we're being creatinine is going to be increased you're gonna start seeing buildup of Weiss in the blood liver is going to be failing to help rid us of those toxins in addition perfusion to the brain because our blood pressures are so low mean arterial pressure is going to drop and so brain isn't going to be able to be perfused so you're gonna start seeing some major mental status changes here you're gonna see confusion agitation until it progresses to the next stage where they'll be actually lossless and a coma their skin is going to be cool clammy but even taking a step further and be modeled and their pulses are going to be absolutely poorer their peripheral pulses and the last stage we have is class four and this is where the patient has lost 40% or more of their fluid volume so greater than 2000 MLS and this is where death is near we need to get this patient some very very fast treatment dynamic treatment if possible to help prevent that and what you're gonna see with this is just all these vital signs that we're talking about they're gonna be significantly abnormal so you're gonna have major tachycardia greater than like 140 severe hypotension and major respiratory failure they're gonna be and Eurex they're not gonna be producing any you're and there's like hardly and you flew it to even produce fluid for urine off of mental status like I said they're gonna be lifeless and in a coma so in a nutshell whenever you're looking for signs and symptoms like for your exams for high potent hypovolemic shock you need to be looking at that heart rate how's it gonna be it's gonna be high it's when we tachycardic how's your blood pressure are gonna be hypotensive rest story right it's going to be increased and their urinary output is going to be decreased their skin perfusion it's gonna be cool clammy capillary refills going to be down Mental Status is going to be confused so be keeping all that in mind and whenever a patient whenever they have like hemodynamic monitoring whenever they start getting in these classes of hypovolemic shock they're gonna have that hemodynamic monitoring so whenever we're looking at central venous pressures how do you think that that number is going to be it's gonna be low this is where you measure the pressure over here in this right reom you don't have any fluid hardly even in the heart so the pressure there is going to be low and if you looked at a pulmonary capillary wedge pressure over here that which looks at the filling pressure in the left atrium it's going to be low as well because we're depleted of our fluid volume so remember those two numbers and it's different whenever we talked about cardiogenic shock remember I talked about the CVP being high that central venous pressure and that pulmonary capillary wedge pressure being high because cardiogenic shock we don't have a loss of fluid volume or hearts just wheat and that fluid volume the pressure of is actually increasing we have fluid volume over loop so those numbers would be high in cardiogenic shock now let's talk about nursing interventions for hypovolemic shock okay what are some treatment goals first because that really dictates where we're going with our nursing interventions one thing of course is replacing flu into this intravascular system we can increase the venous return to the heart we can increase preload stroke volume and increase cardiac output and we get better tissue perfusion so fluids ordered by the physician are really going to help this patient and as a nurse we will be giving those fluids and monitoring them and it can vary it depends on what class or stage of hypovolemic shock that patient is in and you can use various fluids like crystalloids colloids blood blood products and we'll be talking about all those here in a moment and of course correcting the underlying cause of the reason why that patient is losing so much fluid from the intravascular system so if they're having a massive bleed somewhere they need to have surgery repair that to stop of the bleeding so nursing wise we're looking at a lot of things we're looking at circulation perfusion oxygenation and we're going to put our nursing interventions and goals for that patient around that so oxygenation wise we want to make sure that they're getting oxygen because o 2 is a problem here because those cells are being deprived so we want to make sure that they're not entering into respiratory failure so they may need intubation mechanical ventilation place on oxygen circulation wise are they actively bleeding they are you want to hold firm direct pressure call rapid response get someone there to help you fast because you need a team to help you with this patient addition something taneous lee you're gonna be doing all this you're gonna be looking at signs and symptoms of adequate perfusion is this patient going into hypovolemic shock so you're gonna pull from those signs and symptoms that they are and very simple you can look at their skin cool and clammy that would be back look at their Mental Status how are they acting what's their blood pressure their heart right number blood pressure will be low they can be tachycardic will be heart rate will be high urinary output what are they putting out and looking at all those things in addition you want to make sure that you have IV access we need access to that intravascular system so we can give them fluids and drugs whatever we need to get that cardiac output up replace that fluid so you need at least two IVs sites and they need to be a large cannula there in those large veins those antecubital veins a C's at least 18 gauge are higher you're gonna be giving rapid fluids fast and other medication so we want to make sure that they're nice and working in addition they may need a Foley catheter so you can monitor that urinary output precisely collect that instead of depending on the patient to use the bathroom which they're probably going to be so sick they can't do that and we want to be able to collect that and so many patients who have severe hypovolemic shock they're not responding to the fluids I'm gonna have central lines hemodynamic monitoring which will help us monitor the cardiac output and how well we're replacing those fluids and we can look at some numbers so whenever you have a patient in hypovolemic shock severe hypovolemic shock how again is that central venous pressure going to be it's going to be low how's that pulmonary capillary wedge pressure gonna mean it's gonna be low but we're giving them fluids so one thing whenever you give fluids you have to make sure you're not giving them too much we're we're gonna actually flip them into cardiac it overload so if we were giving them too much fluid how would those numbers start presenting central venous pressure can start becoming elevated the pulmonary capillary wedge pressure can be started becoming elevated as well because putting too much fluid in the heart it's too much so it's increasing the pressure over here or right atrium so CVP pressure and the filling pressure on the left atrium for pulmonary capillary wedge pressure so you want to look at those things now position wise what's a good position for these patients we want to position that's going to increase nice cardiac output venous return to the heart so one position is modified Trendelenburg this is where the patient is supine with their feet / legs elevated at that 45 degrees doing that it's going to increase venous return and help us increase cardiac output a bit lab wise we have to monitor what's going on with the patient so physicians will be ordering this and we'll want to be either collecting that and looking at those labs coming out hemoglobin hematocrit looking does this patient need blood products depends on protocols but usually less than eight to seven for hemoglobin they'll need some blood transfusions ABG's arterial blood gases remember these patients can go into acidotic conditions we want to be looking at that looking at lactate levels because our cells are switching from aerobic to anaerobic we're gonna get the buildup of lactic acid livers may not be working building up more toxins or kidneys like an electrolyte CBC's looking at bu in creatinine telling us our renal function now let's talk about our fluid types use for the treatment of hypovolemic shock okay first thing we're going to talk about our crystalloids and colloid solutions these are two types of volume expanders use for hypovolemic shock and again this varies depending on the patient status volume loss of what will be used so first let's talk about crystalloids okay crystalloids what is a crystalloid well normal saline or lactated ringers and how they work is that they add more fluid to the intravascular system and this is going to increase preload because it will increase how much fluids coming back to the heart and stroke volume in the cardiac output so what's this you have to watch for fluid volume overload like I was talking about earlier and you can look for many things just simply listening to their lungs you hear fluid in the lungs with crackles they having difficulty breathing are they having elevated CVP pressures or pulmonary wedge capillary pressures or just looking for edema in legs or do they have jugular venous distention things like that can point to that they're retaining too much of the fluid and one thing about crystalloid solutions I want you to remember is that these solutions are able to diffuse through the capillary wall so less fluid remains in the intravascular system compared to colloid solutions now normal saline or lactated ringers are most commonly used number one they're really cheap easy to access and how they're given is by remembering the three to one rule and what this rule says is for every ml of approximate blood loss three ml's of a crystalloid solution is given so let's say a patient has lost 750 ml of blood how much of a crystalloid solution would they get well according to that rule it would be 2250 MLS because we're going to be giving 3 ml of a crystalloid solution for every ml blood loss another fluid type is colloids and an example of this is like albumin or head of starch and what colloids are they consists of large molecules examples like proteins that can't diffuse through a capillary wall so in the long term more fluid stays in that intravascular system for a longer period of time compared to those crystalloids however colloids are more expensive to use and patients can have anaphylactic reactions so again just with crystalloid solutions as well you would want to monitor for fluid overload now as a nurse it's really important to remember if you are giving large amounts of fluids like these crystalloids colloids it's very important that you warm them before giving them because this will prevent hypothermia and we don't want a patient to go into hypothermia because hypothermia alters the way clotting enzymes work so we want to keep the patient warm keep the fluids warm and but we don't want the patient's sweating so remember that whenever you're giving large amounts of fluids the last floor time gonna talk about of course is blood and blood products this can include packed red blood cells platelets or fresh frozen plasma now packed red blood cells are going to help replace the fluid that has been lost and it's gonna do another thing that really our crystalloids and colloids couldn't do it's going to provide the patient with hemoglobin and hemoglobin will carry oxygen to those deprived cells so that is one benefit of that now it may be used when the patient is not responding to crystalloid fluid challenge has experienced severe bleeding or severe hypovolemic shock and some other type of blood products shoes are like platelets and these would be used for patients who are having uncontrolled bleeding due to thrombocytopenia so they need some platelets to help with that also a fresh frozen plasma this is for when patients need clotting factors now anytime you're giving any type of blood blood products you always want to monitor for transfusion reactions with these products and I have a whole video on the nurses role with blood transfusions if you want to check that out as well okay so that wraps up this video over hypovolemic shock thank you so much for watching don't forget to take the free quiz and 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