Medical-surgical Nursing Demystified

(^40) Medical-Surgical Nursing Demystified
TREATMENT
Treatment depends on severity of symptoms. As always, maintaining open airway,
breathing, circulation, and fluid resuscitation is of vital importance. After stabi-
lization, the focus is on determining and treating the cause of the shock.

• Control bleeding—CBC, stool guaiac test, [to find hidden (occult) blood in
  stool], assess for bleeding.


• Replace fluid—proper fluid replacement depends on the etiology of the shock;
  IV fluid and /or blood products are the choices.

NURSING DIAGNOSES

• Deficient fluid volume


• Ineffective tissue perfusion


• Decreased cardiac output

NURSING INTERVENTION

• IV using 14G catheter (16 or 18 gauge also adequate if not able to obtain 14;
  use largest possible):
  
  
  • Lactated Ringer’s solution (which contains electrolytes) or normal saline
    (0.9 percent).
  
  
  • Blood replacement—type-specific or type O negative, which is the uni-
    versal donor type.
  
  
  
  


• Monitor every 15 minutes:
  
  
  • Blood pressure. If systolic lower than 80 mmHg, then increase oxygen
    flow rate.
  
  
  • Vital Signs every 15 minutes.
  
  
  
  


• Measure urine output each hour with indwelling urinary catheter. Increase
  fluid rate if urine output is less than 30 ml/hour. Be alert for signs of fluid
  overflow. These include, but are not limited to, crackles in the lungs and
  dyspnea.


• Assess for cool, pale, clammy skin, indicating hypovolemic shock.


• Explain to the patient:
  
  
  • What caused the hypovolemia and how to avoid a recurrence.
  
  
  • The purpose of the treatment.