Nursing care plan for shock pdf

Hypotension is the medical term for low blood pressure. Normal blood pressure (BP) for most adults is 120/80 mm Hg. BP less than 90/60 mm Hg is considered hypotensive.

Hypotension is often asymptomatic and does not always require intervention. It only becomes a concern if the pressure is not able to supply oxygen-rich blood to the body’s vital organs. When symptoms appear, the patient may experience lightheadedness, fainting, and weakness. 

Resistance in the blood vessels and cardiac output affects BP. Hypotension can be caused by the following underlying conditions:

• Blood loss (most common cause)
• Hypoventilation
• Changes in posture
• Electrolyte imbalances

Hypotension is categorized according to the following:

• Systolic blood pressure < 90 mm Hg
• Mean arterial pressure < 65 mm Hg
• Diastolic blood pressure < 60 mm Hg

Poor cardiac output due to untreated hypotension can have serious adverse effects. Hypotensive shock is a complication that can result in multi-organ failure and death. Early detection and treatment are important to prevent complications.

The Nursing Process

Asymptomatic hypotension likely does not require investigation or management. If hypotension is occurring as a symptom of a larger issue and continues to worsen, identifying the cause and preventing complications is necessary.

The nurse’s role is to closely monitor blood pressure changes and other vital signs, administer medications and fluids to improve blood pressure, and educate patients on preventing hypotension.

Nursing Care Plans Related to Hypotension

Decreased Cardiac Output Care Plan

Decreased cardiac output associated with hypotension can occur when the body does not receive enough blood from the heart for adequate perfusion. 

Nursing Diagnosis: Decreased Cardiac Output

Related to:

• Reduced cardiac output
• Decreased peripheral vascular resistance
• Diminished blood volume
• Lessened blood viscosity
• Decreased vessel wall flexibility

As evidenced by:

• Decreased blood pressure; less than normal limits
• Bradycardia
• Decreased blood volume
• Blurred vision
• Dizziness or lightheadedness
• Fainting
• Fatigue
• Trouble concentrating
• Low urine output

 Expected outcomes:

• Patient will maintain blood pressure within normal limits
• Patient will verbalize the relationship between cardiac output and blood pressure
• Patient will participate in preventive activities that decrease the workload of the heart and hypotension

Decreased Cardiac Output Assessment

1. Determine the patient’s risk and causative factors.
Hypotension is a symptom of an underlying condition. There is a higher risk in individuals with a history of heart and renal problems.

2. Assess for indications of poor cardiac function and impending heart failure.
The following symptoms may signal poor cardiac function, decreased blood pressure, and impending heart failure:

• Excessive fatigue
• Activity intolerance
• Sudden or increasing weight gain
• Edema of the extremities
• Dyspnea

3. Monitor the patient’s vital signs and hemodynamic parameters.
Hemodynamic monitoring through vital sign assessments, ECGs, central venous pressure, etc., ensure that perfusion is sufficient throughout the body. Monitoring is used to compare, track trends, and gauge the effectiveness of interventions.

4. Review lab values and cardiac diagnostic results.
Review complete blood counts, electrolytes, BUN and creatinine levels, echocardiograms, stress tests, and more to help identify patients who are at risk for cardiac complications and hypotension.

Decreased Cardiac Output Interventions

1. Position the patient comfortably.
A semi-Fowler’s position is recommended to aid cardiac compensation and reduce oxygen consumption.

2. Administer oxygen as ordered.
Oxygen administration increases the oxygen available for heart function and tissue perfusion.

3. Administer medications as ordered.
Inotropic medications increase cardiac contractions to help systemic and cardiac circulation.

4. Monitor intake and output.
If blood pressure is low, there may not be enough blood to support kidney function. Low urine output can signal issues with perfusion.

5. Administer IV fluids and/or blood.
Low circulating blood volumes are a major contributor to hypotension. Ensure adequate volume by administering IV fluids and replacing blood or plasma.

Risk for Unstable Blood Pressure Care Plan

Risk for unstable blood pressure can be caused by autonomic response changes which are responsible for controlling internal functions such as heart rate, body temperature, and blood pressure. If blood pressure is too low, it can result in life-threatening shock.

Nursing Diagnosis: Risk for Unstable Blood Pressure

Related to:

• Medication side effects
• Orthostatic hypotension
• Pregnancy
• Parkinson’s disease
• Autoimmune disorders

As evidenced by:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are aimed at prevention.

Expected outcomes:

• Patient will maintain blood pressure within normal limits
• Patient will not experience hypotensive side effects from medications
• Patient will verbalize strategies to ensure safety related to orthostatic hypotension

Risk for Unstable Blood Pressure Assessment

1. Review the patient’s current medication regimen.
Tricyclic antidepressants, vasodilators, antihypertensives, and diuretics can directly affect blood pressure.

2. Note changes and trends in the patient’s blood pressure readings.
The nurse must accurately assess blood pressure. Incorrect readings can result in delayed treatment or worsening hypotension if being overtreated with antihypertensives.

3. Note the patient’s signs and symptoms of hypotension.
Take note of signs and symptoms such as dizziness or syncope. Early recognition of symptoms can prevent possible complications.

4. Assess the patient’s and caregiver’s knowledge of hypotension.
Low blood pressure may be a sign of an underlying health problem. Inquire about the patient’s and/or caregiver’s understanding of how to prevent or manage hypotension.

Risk for Unstable Blood Pressure Interventions

1. Manage the underlying condition.
Patients who are pregnant, have autoimmune diseases, or Parkinson’s disease are at risk for hypotension. Ensure the proper management of other comorbidities.

2. Encourage the patient to position from supine to standing slowly.
Instruct the patient to change from a supine/ sitting to a standing position slowly. Orthostatic hypotension occurs when blood pressure drops when standing, decreasing blood supply to the brain. This can increase the risk of falling or fainting and can be avoided by changing positions slowly.

3. Ask the patient to demonstrate the proper checking of blood pressure.
Ensure the patient’s equipment is calibrated correctly. Have them demonstrate to ensure accuracy. Advise the patient to keep a journal throughout the day and note any symptoms, patterns, and causative factors.

4. Have the patient teach back the causes of hypotension and how it can be prevented and treated.
The following behavior and lifestyle modifications should be taught to the patient to improve blood pressure:

• Eating habits
• Exercise
• Smoking cessation
• Stress management
• Substance abuse programs

5. Ensure adequate hydration.
Dehydration often causes hypotension. Encourage the patient (if not contraindicated) to drink plenty of fluids, especially in the event of vomiting or diarrhea.

Risk for Shock Care Plan

Risk for shock associated with hypotension can be caused by not having enough blood volume to perfuse the brain and other organs.

Nursing Diagnosis: Risk for Shock

Related to:

• Decreased blood pressure; less than normal limits
• Decreased blood volume (hypovolemia)
• Decreased oxygen level in the blood (hypoxemia)
• Decreased oxygen level in the tissue (hypoxia)

As evidenced by:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are aimed at prevention.

Expected outcomes:

• Patient will be able to demonstrate hemodynamic balance as evidenced by vital signs within normal limits

Risk for Shock Assessment

1. Assess the patient’s risk factors.
Risk factors that can lead to hypotension and shock include the following:

• Trauma
• Surgery
• Poor coagulation
• Anticoagulant medication
• Organ bleeding
• Persistent vomiting
• Diarrhea
• Diabetes insipidus
• Improper use of diuretics
• Sepsis
• Burns

2. Monitor the patient’s blood pressure.
Severe hypotension is considered a hallmark sign of shock. Note the presence of the following:

• Low blood pressure (hypotension)
• Narrowing range between systolic and diastolic BP (narrow pulse pressure)

3. Review laboratory and diagnostic studies results.
Assess for the presence of bleeding through coagulation results and diagnostic scans to determine the cause of shock.

Risk for Shock Interventions

1. Collaborate with the healthcare team.
Collaborate with the healthcare team for immediate management of bleeding causing hypotension and shock. Managing shock is an emergency that requires a team to administer fluids, blood products, medications, and oxygenation.

2. Administer vasopressors.
Vasopressors such as epinephrine or vasopressin constrict blood vessels to raise blood pressure.

3. Note for bleeding signs and symptoms.
Recognize the following signs and symptoms of bleeding that can lead to hypotension and shock:

• Pain that is not relieved by pain medications
• Unresolved bleeding
• Excessive fluid loss
• Persistent fever and chills
• Skin pallor
• Faintness, dizziness, or confusion

4. Place in Trendelenburg position.
Positioning the patient with their head lower than their feet can raise blood pressure and aid in perfusion to the brain and vital organs.

References and Sources

1. Dewit, S. C., Stromberg, H., & Dallred, C. (2017). Care of Patients With Diabetes and Hypoglycemia. In Medical-surgical nursing: Concepts & practice (3rd ed., pp. 1823). Elsevier Health Sciences.
2. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
3. Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook of medical-surgical nursing (13th ed., p. 971). Wolters Kluwer India Pvt.
4. Sharma, S., Hashmi, M. F., & Bhattacharya, P. T. (2022, February 16). Hypotension – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK499961/

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