Mayra Pagan

Potential complication: hypovolemic shock

related to excessive blood loss/MVA

Desired Outcome

The client will not develop hypovolemic shock as evidenced by:

1.usual mental status
2.stable vital signs
3.skin warm and usual color
4.palpable peripheral pulses
5.urine output at least 30 ml/hour.

Nursing Actions and Selected Purposes/Rationales

1.Assess for and immediately report signs and symptoms of conditions that indicate
impending aneurysm rupture:
A.leaking aneurysm:
I.increasing abdominal girth
II.ecchymosis of flank area or perineum
III.frank or occult gastrointestinal bleeding (occurs if the aneurysm ruptures into the
duodenum)
IV.decreasing RBC, Hct, and Hb levels
V.new or increased reports of lumbar, flank, abdominal, pelvic, or groin pain
(accumulation of blood in the peritoneum and/or retroperitoneal spaces causes
irritation of and pressure on the tissues and nerves)
VI.diminishing or absent peripheral pulses
VII.further decline in thigh B/P as compared with B/P in arm (thigh B/P is usually
slightly lower than B/P in arm of a client with an abdominal aortic aneurysm)

B.expanding aneurysm: I.new or increased reports of lumbar, flank, or groin pain

(results from pressure on lumbar nerves)

II.increased size of pulsating mass in abdomen

III.increasing sense of abdominal and/or gastric fullness (results from pressure on
duodenum)
IV.decreasing motor or sensory function of lower extremities (results from pressure
on lumbar and/or sacral nerves).

2.Assess for and report signs and symptoms of hypovolemic shock:

A.restlessness, agitation, confusion, or other change in mental status
B.significant decrease in B/P
C.postural hypotension
D.rapid, weak pulse
E.rapid respirations
F.cool skin
G.pallor, cyanosis
H.diminished or absent peripheral pulses
I.urine output less than 30 ml/hour.

3.Implement measures to decrease risk of aneurysm rupture: A.instruct client to

avoid elevating legs when in bed, using knee gatch, and crossing legs in order to
prevent restriction of blood flow to the lower extremities and subsequent increase in
vascular pressure at the aneurysm site
B.perform actions to prevent an increase in blood pressure: I.limit client's activity as
ordered
II.instruct client to avoid activities that create a Valsalva response (e.g. straining to
have a bowel movement, holding breath while moving up in bed, lifting heavy
objects)
III.implement measures to reduce fear and anxiety (see Preoperative Diagnosis 1)

C.administer antihypertensives if ordered to reduce pressure in the dilated vessel.

4.If signs and symptoms of hypovolemic shock occur: A.place client flat in bed
unless contraindicated

B.monitor vital signs frequently

C.administer oxygen as ordered
D.administer blood and/or volume expanders as ordered (these need to be used
with caution since increased vascular pressure can extend a tear at site of rupture)
E.prepare client for insertion of hemodynamic monitoring devices (e.g. central
venous catheter, intra-arterial catheter) if indicated
F.prepare client for emergency surgical repair of aneurysm if indicated.