© 2017 DEANNE A. BLACH, MSN, RN Major vascular surgery 2 weeks ago - Femoral-Popliteal Bypass Graft. HYPOVOLEMIC SHOCK COLLABORATIVE CARE INTERVENTIONS John Dearing, admitted with internal bleeding from a torn vascular graft repair. Hemorrhage (with loss of O2 carrying RBCs) and hypovolemia → loss of circulating or • Administer oxygen. intravascular volume → ↓ venous return → • Ensure adequate organ and extremity perfusion. ↓ preload → ↓ SV and CO → ↓ MAP. • Administer fluids (crystalloids, colloids, blood Results in & other blood products). • Administer vasoactive medications. ASSESSMENT DATA • Administer positive inotropic medications. Class II hypovolemia → fluid volume loss • Ensure sufficient hemoglobin and hematocrit. ↓ Mean Arterial Pressure (MAP) • Initiate nutritional support therapy. 15%- 30% (volume loss of 750 to 1500 mL) Ineffective Tissue Perfusion • Institute evidence-based practice protocols to prevent complications. • Assess response to therapy. - Skin pale and cool. - ↓ Peripheral pulses. Medical Management Collaborative Care Interventions Include - ↑ Anxiety. - ↑ RR. NURSING INTERVENTIONS - ABGs → respiratory alkalosis ↓ PaCO2. - Flat jugular veins. Assess patient’s response to fluid and effects of therapy • Prevent shock from progressing by - ↓ CVP or RAP and pulmonary artery correcting the cause - surgical repair of graft. occlusion pressure (PAOP). • Restore tissue perfusion. • Assess patient at least every 15 minutes until - HR > 100 beats/minute. • Prevent complications. - Postural hypotension. shock is controlled and condition improves. • Monitor LOC, pulse (rate, regularity, quality), BP, - Pulse pressure narrows as diastolic BP. pulse pressure, CVP, respiratory rate, skin color, - Urine output ↓ 20 -30 mL/hour. P O2 saturation, cognition and urine output. A - Urine sodium ↓, ↑ osmolality & ↑ • Hemodynamic monitoring of intra-arterial T specific gravity. The patient will demonstrate adequate tissue perfusion by: pressure, mixed venous oxygen saturation I (SvO2), pulmonary artery monitoring, and E PRIORITY NURSING DIAGNOSES pulmonary capillary wedge pressures. N • Prevent & be alert for complications. T • Minimize fluid loss: limit blood sampling, • Deficient Fluid Volume R/T active blood loss. O • Maintaining an O2 Sat at 95% or greater. observe lines for accidental disconnection & • Decr eased Cardiac Output R/T alterations in U • ABGS within the normal range. apply direct pressure to bleeding sites. preload T • Maintenance of urine output at least 30 mL/hr, • For hypotension, position patient with legs ↑, • Anxiety R/T threat to biologic, psychologic, C • Maintenance of mean arterial blood pressure trunk flat with head and shoulders above chest. within 10 mm Hg of baseline. • Monitor for SIRS, which may occur for up to and/or social integrity O several days after resuscitation. M E • Provide additional post-operative care for S patient’s vascular graft surgical repair. • Provide comfort and emotional support. .