Page 305 - Critical Care Nursing Demystified

290 CRITICAL CARE NURSING DeMYSTIFIED

Hallmark Signs and Symptoms (Late)

• Lethargy leading to coma
• MAP less than 60 mm Hg
• Decreasing hypotension
• Decreasing CO

• Doppler pulses

Treatment
Classification of hemorrhagic shock is important to identify and the treatment
is matched with the signs/symptoms of shock the patient exhibits. Table 6–7
shows the classes of shock and treatment.

TABLE 6–7 Classifications of Hemorrhagic Shock and Treatment

Estimated
Class of Shock Blood Loss Signs/Symptoms Treatment
Class I 15% (750 mL) Tachycardia may be Crystalloid Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
only symptom infusions
May be slightly anxious
Class II 15%–30% Tachycardia Crystalloid
(750–1,500 mL) Decreased pulse resuscitation
pressure
Anxiety
Mildly decreased
urinary output
Class III 30%–40% Heart rate >120 Crystalloid, col-
(uncompen- (1,500–2,000 mL) Change in mental loid fluid resusci-
sated shock) status tation and blood
replacement
Drop in systolic BP
20 mm Hg drop in MAP
Class IV >40% Heart rate >140 Crystalloid, blood
(>2,000 mL) Tachypnea replacement

Marked changes in Oxygenation with
mental status any means to
increase the PO
MAP <60 to normal levels 2
Pale, cool, clammy skin Pressor therapy
Sluggish capillary refill