Managing hypovolemia

Nursing, Feb 1997 by Sandrock, Jean

Don't let the current protocol for treating a patient's volume deficit throw you. Here's how to follow the appropriate algorithm.

This morning, 16-yearold Joshua was thrown from a horse; now he's in your emergency department complaining of leftsided abdominal pain. His skin is pale and moist, and he's lying quietly in the bed. He opens his eyes when you call his name and appears to be breathing adequately.

He tells you that he felt fine immediately after the fall, but started to have abdominal pain about 2 hours later. He went home and lay on the couch. When his parents found him a short time later, they rushed him to the hospital.

You check Joshua's airway, breathing, circulation, and responsiveness. His vital signs are: blood pressure, 72/50; pulse, 122 and weak; respirations, 24; and temperature, 97.2deg F (36.2degC). You start an intravenous (I.V.) infusion of 0.9% sodium chloride solution and connect Joshua to cardiac and pulse oximetry monitors. His rhythm is sinus tachycardia and his Spo^sub 2^ is 93%. You administer oxygen at 4 liters/minute via nasal cannula.

You auscultate his abdomen-bowel sounds are slightly hypoactive but present in all quadrants. His abdomen is firm and tender to palpation, and he complains of pain over the left upper quadrant. Joshua answers questions appropriately but appears restless. He says he's thirsty and repeatedly asks for a drink of water.

Your examination also reveals:

a 3-inch (7.5-cm) bruise beginning to appear on the left side of his abdomen

small abrasions on the forehead and left knee

a 1-inch (2.5-cm) scalp laceration on the occiput with a small amount of blood at the site

clear and equal lung sounds bilaterally.

1. Which of the current advanced cardiac life support algorithms would be the best choice for managing Joshua's care?

a. pulseless electrical activity (PEA)

b. tachycardia with a pulse

c. hypothermia

d. hypotension, shock, pulmonary edema

Answer: d. Joshua is exhibiting signs of hypotension and hypovolemic shock. Option a, the PEA algorithm, isn't appropriate because Joshua has a palpable pulse and blood pressure. The tachycardia algorithm, option b, isn't appropriate because his heart rate of 122 is probably compensatory for his volume deficit or a sign of anxiety. The hypothermia algorithm (option c) also isn't correct; Joshua's temperature is only slightly lower than normal and isn't a high priority.

2. The most appropriate nursing diagnosis would be

a. alteration in comfort: pain secondary to fall from a horse.

b. ineffective airway clearance secondary to inability to cough.

c. potential or actual fluid volume deficit related to abdominal injury.

d. anxiety related to potential upcoming surgery.

Answer: c. Joshua is showing signs of hypovolemic shock: hypotension, pale and moist skin, thirst, and restlessness. You suspect intra-abdominal bleeding-possibly from a ruptured spleen-and focus on the fluid volume deficit.

Although alteration in comfort: pain from a fall from a horse (option a) is a concern, it shouldn't be the initial priority. Address pain management after the diagnosis is confirmed; giving Joshua analgesics now may mask signs of injury and complicate the surgical evaluation. Option b is incorrect because your assessment showed clear lungs, a patent airway, and equal chest expansion. Option d is incorrect because Joshua's restlessness is most likely related to hypovolemic shock and hypotension.

3. The most appropriate therapy for Joshua would include

a. dopamine infusion at 5 mcg/kg/minute; oxygen at 6 liters/minute by mask.

b. DW infusion at 100 ml/hour; oxygen; keep the patient warm.

c. 2,000 ml of oral fluids over 1 hour; oxygen; Spo2 monitoring.

d. two large-bore I.V. lines infusing 0.9% sodium chloride solution or lactated Ringer's solution; oxygen; keep the patient warm.

Answer: d. Crystalloids such as lactated Ringer's and 0.9% sodium chloride solution are the superior replacement I.V. fluids. Establish two large-bore lines because Joshua has lost a significant amount of blood and needs quick volume replacement. Oxygen therapy is essential because blood loss means less oxygen is getting to the cells. You'll also keep Joshua warm to prevent shivering, which increases the cellular oxygen demands and compounds shock.

Option a is incorrect because using vasopressors before adequate fluid replacement can cause further hemodynamic deterioration.

Option b is wrong because D^sub 5^W, which doesn't have the volume-expanding properties of the other crystalloids, isn't the solution of choice.

Oral fluid intake, option c, isn't appropriate because Joshua will probably need surgery and should be kept N.P.O.

Hypovolemia can be relative or actual. In relative hypovolemia, vascular tone is inadequate to support circulation and maintain blood pressure. Actual hypovolemia, such as Joshua's, occurs when blood or fluid loss contributes to a total fluid volume deficit. In Joshua's case, aggressive care is needed to restore fluid lost through intra-abdominal bleeding.

You infuse 1 liter of 0.9% sodium chloride solution (about 20 ml/kg) through Joshua's I.V. line. His blood pressure increases to 80/52, with a pulse of 128 and respirations of 20. He's still pale, slightly moist, and slightly restless. The results of his lab tests arrive: hemoglobin, 8.4 grams/dl; hematocrit, 25%; red blood cells, 4.83x10^sub 6^/mm^sub 3^; white blood cells, 10.6x10^sub 3^/microliter; sodium, 147 mEq/liter; potassium, 3.6 mEq/ liter; chloride, 109 mEq/liter.