Hypovolemic Shock NCLEX Review
of blood draining back to the heart) -> this
What is hypovolemic shock? It occurs when there is a
LOW fluid volume in the intravascular system.
Hypo: low
Vol: Volume
Emic: blood
“low blood volume”
The intravascular system is the space that contains the
volume of blood in a person’s circulatory system.
Therefore, if there is a decrease in the volume of blood
in a person’s circulatory system, what does the heart
have to pump? Hardly anything at all!
If the amount of blood the heart pumps to the
organ/tissues DECREASES, the cardiac output
decreases. This will lead to decreased tissue perfusion,
which will alter the function of cells. It will limit their
access to oxygen and signs and symptoms of shock will
occur.
A person needs to lose about 15% or MORE of their
intravascular volume for the hypovolemic shock to
occur.
The average human blood volume is 5 L (the exact
amount depends on the person’s size). So, if a person has
a blood volume of 5 L and loses 1 L of blood volume
(1,000 mL), that would be 20% of their blood volume.
This person would start showing signs and symptoms of
hypovolemic shock.
Causes of Hypovolemic Shock
What can lead to a loss of fluid volume in the
intravascular system?
Any condition that leads to fluid leaving the body
externally or there is shifting of fluid within the body
that leaves the intravascular space.
Relative hypovolemic shock: this is an INSIDE fluid
shift from the intravascular system (this tends to be more
concealed than absolute)
 Fluids or blood collecting or leaking inside the body
from internal bleeding, third-spacing of fluid
(severe burns due to increased capillary
permeability), fracture of long bones, damage to
organs like the pancreas…example: Cullen or
Turner’s Sign.
 Massive vasodilation from septic shock
Absolute hypovolemic shock: this is an OUTSIDE
fluid shift from the intravascular system that leaves the
body (this tends to be more noticeable compared to
relative)
 Massive bleeding from injury or surgery
 Excessive fluid loss from oral (vomiting), GI
(diarrhea), GU (urine), and integumentary
(sweating)…..many times this is caused by a disease
process (diabetes or endocrine disorders) or illnesses
Pathophysiology of Hypovolemic Shock
There’s major depletion of volume in the intravascular
system (relative or absolute cause) -> this decreases the
amount of venous return to the heart (this is the amount
DECREASES preload (the amount the ventricles stretch
once their filled with blood)…they won’t be stretching
very much because there isn’t much fluid to fill them ->
this decreases stroke volume (the amount of blood
pumped by the left ventricle with each beat -> this
DECREASES CARDIAC OUTPUT (this is the amount
of blood the heart pumps per minute….4-8 Liters per
minute…CO = HR x SV)
-If cardiac output falls too low, the amount of blood that
should be going to the organs/tissues cells per minute
will drastically fall.
And guess what important substance is in the blood that
the cells of the organs and tissues rely on to survive?
OXYGEN!
But since the amount of blood that reaches them is low,
the cells won’t receive enough oxygen to function and
hypoxic injury to the cell can occur.
The body will attempt to compensate by activating
the sympathetic nervous system, which will trigger the
body’s built-in survival system.
Now, based on the percentage of the fluid volume that is
lost will determine the signs and symptoms the patient
may present with and what stage the patient is likely in.
Hypovolemic shock can be divided into four stages or
classes, and these are like the stages of shock we just
reviewed in this series, but these stages are based on the
percentage of fluid volume loss.
Remember the numbers: 15, 15-30, 30-40, 40% , and
what is happening to the blood pressure, heart rate,
urinary output, mental status, and the skin.
Class I : <15% of volume loss….up to 750 mL in an
adult
The body can maintain cardiac output with this volume
loss. The patient is mainly asymptomatic with this class.
 Heart rate within normal limits (less than 100 bpm)
 Blood pressure, respiratory rate, within normal
limits
 Skin pink, warm, and capillary refill normal (<2
seconds)
 Normal urinary output (greater than 30 mL/hr)
 Mental status: normal…may be a little anxious
Class II: 15-30% of volume loss….750-1500 mL in an
adult
Cardiac output is starting to fall due to volume loss.
There is major body system compensation via the
sympathetic nervous system, renin-angiotensin system,
and the shunting of blood to vital organs.
 Heart rate will increase…. tachycardia (greater than
100 bpm) due to the effects of the SNS
 Blood pressure decreases but within normal limits
(for now due to vasoconstriction)
 Respirations increase (mild)…due to low oxygen
level in the body
 Urinary output will start to lower (20-30 mL/hr)
….blood flow is shunted and body will start to keep
water from aldosterone and ADH being released due
to angiotensin II
 Skin: cool, clammy, increased capillary refill >2
seconds…blood flow diverted to vital organs
 Diminished peripheral pulses
 Mental status: mild anxiety
Class II: 30-40% of volume loss….1,500-2000 mL in
an adult
The body can’t compensate anymore….it’s exhausting!
Therefore, cardiac output falls so low that tissue
perfusion is altered, which causes the cells that make up
the organs to malfunction…. heart, liver, lungs, kidneys,
brain, etc.
 Heart rate increased (significant tachycardia >120
bpm)
 Respiratory increased….progressing to respiratory
failure
 Hypotension
 Oliguria (<30 mL/hr)….renal failure…high BUN
and creatinine
 Poor peripheral pulses
 Skin: very cool, mottled, capillary refill >2 seconds
 Mental status: very anxious and
confused…..acidosis, low oxygen, and low perfusion
to the brain
Class IV: >40% of volume loss……more than 2,000
mL in an adult
Death is very near…. needs very dynamic treatment!
The body is shutting down….the fluid loss is SEVERE!
 Significant tachycardia (>140 bpm), increase
respiratory (respiratory failure), severe hypotension,
anuria (no urine production), mental status: lifeless,
coma
*Source: Class/Stage volume loss percentage and
amount of volume loss modified from American College
of Surgeons Guidelines
Signs and Symptoms of Hypovolemic Shock
Remember it depends on the percentage of volume loss,
but in a nutshell: tachycardia, hypotension, cool/clammy
skin, weak peripheral pulses, anxiety, decreased urinary
output…..central venous pressure: low, PAWP/PCWP:
low
Nursing Interventions for Hypovolemic Shock
Treatment goals: fluid resuscitation, correct underlying
cause that is leading to the fluid loss….example:
hemorrhaging: surgery (get the patient ready for surgery)
Nursing Interventions
Monitor oxygenation and perfusion status of the patient:
place on oxygen, may need intubation and mechanical
ventilation, what is the patient’s hemodynamic status?
blood pressure, heart rate, rhythm, tissue perfusion to
organs: mental status, urinary output (will need catheter
insertion to closely monitor urinary output…UOP needs
to be greater than 30 mL/hr)
If bleeding, hold firm, direct pressure.
If showing signs and symptoms of hypovolemic shock,
place in modified Trendelenburg position (feet at 45’
and head flat….increases venous return to heart and
cardiac output).
Obtain IV access (at least two IV sites that are
large….18 gauge or bigger in a large vein like
antecubital)…needed for rapid fluid delivery and other
medications….many patients with severe hypovolemic
shock (especially ones who are not responding to fluid
treatment) will have a central line and hemodynamic
monitoring to monitor cardiac output and fluid
replacement.
Collect labs: hgb, hct (blood level), lactate level (status
of cell’s metabolism), blood gases (acidosis?),
electrolytes, bun, and creatinine
Severe hypovolemic shock: Central Venous Pressure
(low) and PAWP/PCWP (low)
Fluids for Hypovolemic Shock
Crystalloids and colloids Solution are two types of
volume expanders used in hypovolemic shock: varies
depending on the patient’s status and volume loss
Crystalloids:
Normal Saline or Lactated Ringer’s: Isotonic fluids
that will add more fluid to the intravascular system…
increasing preload, stroke volume, and cardiac output
 most commonly started out on a
crystalloid solution
 watch for fluid volume overload
o If in fluid overload,
hemodynamic monitoring
may show: elevated CVP
or PWCP/PAWP
o Auscultate for fluid in the
lungs…crackles
o Edema, jugular venous
distention
Remember the 3:1 rule for crystalloid solutions: For
every 1 mL of approximate blood loss, 3 mL of
crystalloid solution is given.
**** Crystalloid solutions are able to diffuse through
capillary wall, so there is less fluid that remains in the
intravascular space compared to colloid solutions.
Colloids:
Albumin, Hetastarch: made up of large molecules
(example: proteins) that can’t diffuse through the
capillary wall so more fluid stays in the intravascular
space for longer

 more expensive
 patient can have an anaphylactic reaction
 monitor for fluid overload
***If giving large amount of fluids, need
to WARM them.

WHY? If not warmed, it can lead to hypothermia, and

this will alter clotting enzymes. Keep the patient warm,
but not to the point of sweating.

Blood and Blood Products: Packed Red Blood Cells,

Platelets or Fresh Frozen Plasma (FFP):

PRBCS: helps replace fluid and provides the patient

with hemoglobin, which will carry oxygen to deprived
cells (crystalloids and colloids can’t do this)….these
types of fluid may be used when the patient is not
responding to crystalloid fluid challenge, experiencing
severe bleeding/severe hypovolemic shock etc.  

Platelets: for uncontrolled bleeding to help with

thrombocytopenia

Fresh Frozen Plasma: for when the patient needs

clotting factors

****monitor for transfusion reaction with these

products