Page 306 - Critical Care Nursing Demystified

Chapter 6 CARE OF THE TRAUMATIZED PATIENT 291

Nursing Diagnoses for
Hemorrhagic Shock Expected Outcomes
Fluid volume deficit The heart rate will be below 100
The BP will be above 100 systolic
The patientʼs weight will be baseline
The urinary output will be 30 cc/hr continuously
Tissue perfusion, decreased All peripheral pulses will be intact
Decreased cardiac output The heart rate will be below 100
The BP will be above 100 systolic
The MAP will be above 80 mm Hg
The urinary output will be 30 cc/hr continuously

Nursing Interventions

Perform ongoing assessments of hemodynamic parameters prioritized by the
ABC method including VS, SaO , MAP, and ABGs to determine circulatory
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status.
Elevate lower extremities to enhance blood return to the heart and decrease 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.
peripheral venous pooling.
Obtain estimated blood losses from first responders prn to anticipate the level
of shock and appropriate treatment.
Administer oxygen to prevent hypoxia.

Administer and monitor the effects of fluid volume replacement therapy to
bring the amount of fluid in the intravascular space up quickly to prevent hypox-
emia and resultant organ failure (see Table 6–3 and section on FVR for addi-
tional nursing care).
Administer vasopressors like dopamine once IVF has been given to raise the
BP and prevent multiple organ system failure (MOSF).
Apply external pressure to the bleeding site or prepare the patient for sur-
gery if bleeding cannot be controlled.
Administer supplemental oxygen to load up the hemoglobin molecules with
oxygen in order to deliver more to the tissues.
Monitor urinary output, weight, and BUN and creatinine to determine if renal
damage has occurred due to hypoperfusion.
Assess neurological status to determine if cerebral damage has occurred due to
hypoperfusion.