Saint Louis University

School Of Nursing

CASE PRESENTATION
(HYPOVOLEMIC SHOCK)
Submitted by:
CAS-OY, Meck Malone C.
FERNANDO, Steward P.
GURION, Elpidio Gregorio D.
ALCANTARA, Michelle D.
BASTA, Gilyann Joy C.
DAYAO, Carla Nicole C.
KARGANILLA, Jan Christy A.
MAMUAD, Ivy Jenica S.
NEBRES, Mary Joy D.
PALMERO, Chiki Rose B.
RULLODA, Jimalowe R.
VALDREZ, Agatha Nicole C.
BSN IV-B4
Submitted to:
Jertrude Biado, RN
Instructor

August 2012

PATIENTS PROFILE
Name: Patient Y
Age: 12 y/o
Sex: Female
Nationality: African-American
Final Diagnosis: Hyperglycemic Hyperosmolar Syndrome
History of Present Illness:
Four to five days prior to consultation, patient had been having upper-respiratory symptoms with diarrhea and vomiting for three days. Patient complained of being thirsty
and had been supplementing her diet with milkshakes and smoothies. The night prior to consultation, patient awoke somewhat disoriented, which the parents assumed was a bad
dream. On the day of consultation, patient became progressively weak, sleepy, and lethargic.
Family Health History:
There is a paternal family history of Type 1 Diabetes and no history of gestational diabetes. There is also a significant family history for obesity.

LABORATORY RESULTS
ABG
pH
PCO2
HCO3
PaO2
WBC

Hct
Platelet

7.12
50 mmHg
15 mM
99 mmHg

Partially compensated metabolic

acidosis

CBC
14.6/ uL
High: If the WBC count exceeds the
N= 4.3 K/uL to 10
normal range, it would indicate that the
K/uL
person has an infection. This is
because the leukocytes increase in
number to fight off foreign substance
that has entered the system.
37 %
Within Normal range
N= 36.1 to 44.3%
507, 000/ uL
High: Can Cause:
N= 150,000 - 400,000
Excessive bleeding
platelets per
microliter (mcL)
Fainting or feeling light-headed

Hematoma (blood
accumulating under the skin)

Infection (a slight risk any time

the skin is broken)

Sodium

137 mM

Potassium

5.2 mM

Chloride
Phosphorus
Serum
glucose
Osmolality

102 mM
4.5 mg/dL
2636
mg/dL
466
mOsm/ L

Corrected Na=Measured
Na +1.6 (glucose
(mg/dL)-100
=185 mM
N= 135 - 145
millimoles/liter (mmol/L)
N= 3.5 - 5.0
millimoles/liter (mmol/L

N= 98 - 108 mmol/L
N= 2.5 4.5 mg/dL
N= 70 and100 milligrams
per deciliter (mg/dL)
N= 275 to 295
milliosmoles per kilogram

High: Increased potassium is known as hyperkalemia. Potassium is normally

excreted by the kidneys, so disorders that decrease the function of the kidneys
can result in hyperkalemia. Certain medications may also predispose an
individual to hyperkalemia.
> Increase levels occur with excessive IV administration, acute or chronic renal
failure, potassium sparing diuretics, infection, and dehydration.
Within normal range
Within normal range
Very high: higher most often means you have diabetes

High: may be due to:

Dehydration

Diabetes insipidus

Ethylene glycol poisoning

Hyperglycemia

Hypernatremia

Methanol poisoning

Stroke or head trauma resulting in deficient ADH secretion

Uremia
>When osmolality in the blood becomes high, the body releases antidiuretic
hormone (ADH). This hormone causes your kidney to reabsorb water, which
results in more concentrated urine. The reabsorbed water dilutes the blood,
allowing the blood osmolality to fall back to normal.
BUN

77 mg/ dL

N= 6 23 mg/dL
High: Higher-than-normal levels may be due to:

Congestive heart failure

MEDICATIONS
Brand Name: Intropin, Revimine
Generic Name: Dopamine hydrochloride
Classification: Cahecholamine adrenergic, Inotropic, vasopressor
MOA: Causes norepinephrine release (mainly on the dopaminergic receptors),
leading to vasodilation of renal and mesenteric arteries. Also exerts intoropic effects
on heart, which increases the heart rate, blood flow, myocardial contractility, and
stroke volume.
Indication:
> Shock
> hemodynamic imbalance
> hypotension
Contraindication:
> Hypersensitivity to drug or bisulfates
> Tacchyarrythmias
> Ventricular fibrillation
> Pheochromocytoma
Adverse reactions:
> CNS: headache
> CV: palpitations, hypotension, angina, ECG chanes, tachycardia, vasoconstricvtion,
arrhythmias
> EENT: mydriasis
> GI: nausea and vomiting
> Metabolic: azotemia, hyperglycemia
> Respiratory: Dyspnea, asthma attacks
> Skin: piloerection
> Other: irritation at injection site, gangrene of extremities (with high doses for
prolonged periods or in occlusive vascular disease)
Nursing Responsibilities:
> Monitor blood pressure, pulse, urinary output and pulmonary artery wedge
pressure during infusion.
> Inspect I.V site regularly for irritation. Avoid extravasation.

> Monitor color and temperature of extremities

> Never stop infusion abruptly, because this may cause severe hypotension.
Brand Name: Vancocin
Generic Name: Vancomycin hydrochloride
Classification: Tricyclic glycopeptide, Anti - infective
MOA: Binds to bacterial cell wall, inhibiting cell wall synthesis and causing
secondary damage to bacterial membrane
Indication:
> Severe, life threatening infections caused by susceptible strains of methicillin
resistant staphylococci, Staphylococcus epidermidis, Streptococcus viridians,
Streptococcus bovis or Streptococcus faecalis.
> Endocarditis prophylaxis in penicillin allergic patients at moderate risk who are
scheduled for dental and other invasive procedures
> Enterocolitis caused by Streptococcus aureus; antibiotic related
pseudomembranous diarrhea caused by Clostridium difficile
Contraindication:
> Hypersensitivity to drug
Adverse reaction:
> CV: hypotension, cardiac arrest, vascular collapse
> EENT:permanent hearing loss, ototoxicity, tinnitus
>GI: nausea, vomiting, psedomembranous colitis
>GU: nephrotoxicity, severe uremia
> Hematologic: eosinophilia, leukopenia, neutropenia
> Respiratory: wheezing, dyspnea
>Skin: red man syndrome (nonallergic histamine reaction with rapid IV infusion),
rash, urticaria, pruritus, necrosis
>Other: chills, fever, thrombophlebitis at injection site, anaphylaxis
Nursing Responsibility:
> Monitor closely for signs and symptoms of hypersensitivity reactions, including
anaphylaxis.

> Assess BUN and creatinine levels in patients with unstable renal function.
> Monitor urine output daily.
> Stay alert for hearing loss
> Check IV site often for phlebitis
> Watch for red man syndrome, which can result from rapid infusion. Signs and
symptoms include hypotension, pruritus, and maculopapular rash on face, neck,
trunk and limbs.
> Monitor CBC. Watch for signs and symptoms of blood dyscrasias.
> Monitor respiratory status. Stay alert for wheezing and dyspnea.
Brand Name: Rocephin
Generic Name: Ceftriaxone Sodium
Classification: Third generation cephalosporin, anti - infective
MOA: Interferes with bacterial cell wall synthesis and division by binding to cell wall,
causing cell death. Active against gram negative and gram positive bacteria, with
expanded activity against gram negative bacteria. Exhibits minimal
immunosuppressant activity.
Indication:
> infection of respiratory system, bone, joints and skin; septicaemia
Contraindication: hypersensitivity to cephalosporins or penicillins
Adverse reaction:
> CNS: headache, confusion, hemiparesis, lethargy, paresthesia, syncope, seizures
> CV: hypotension, palpitations, chest pain, vasodilation
> EENT: hearing loss
> GI: nausea, vomiting, diarrhea, abdominal cramps, oral candidiasis,
pseudomembranous colitis
> GU: vaginal candidiasis, nephrotoxicity
> Hematologic: lymphocytosis, eosinophilia, bleeding tendency, haemolytic anemia,
hypoprothrombinemia, neutropenia, thrombocytopenia, agranolocytosis, bone
marrow depression
> Hepatic: hepatic failure, hepatomegaly
> Musculoskeletal: arthralgia
> Respiratory: dyspnea
> Skin: urticaria, maculopapular rash, erythematous rash
> Others: chills, fever, superinfection, anaphylaxis, serum sickness

Nursing Responsibility:
> Monitor foe extreme confusion, tonic clonic seizures, and mild hemiparesis
> Assess CBC and kidney, liver function test
> Monitor for signs and symptoms of superinfection and other serious adverse
reactions
> watch out for a reduced urine output, persistent diarrhea, bruising or bleeding.
Brand Name: Lovenox
Generic Name: Enoxaparin Sodium
Classification: Low molecular weight heparin, Anticoagulant
MOA: inhibits thrombus and clot formation by blocking factor Xa and factor IIa. This
inhibition accelerates formation of antithrombin III thrombin complex (a coagulation
inhibitor) thereby deactivating thrombin and preventing conversion of fibrinogen to
fibrin.
Indication: Prevention of pulmonary embolism and deep vein thrombosis , prevention
of ischemic complications of nstable angina or non Q wave myocardial infarction
Contraindication: hypersensitivity to drug, heparin, sulphites, benxyl alcohol or pork
products, thrombocytopenia, active major bleeding
Adverse reaction:
CNS: dizziness, headache, insomnia, confusion, cerebrovascular accident
CV: edema, chest pain, atrial fibrillation, heart failure
GI: nausea, vomiting, constipation
GU: urinary retention
Hematologic: anemia, bleeding tendency, thrombocytopenia, hemorrhage
Metabolic: hyperkalemia
Skin: bruising, pruritic rash, urticaria
Other: fever, pain, irritation, erythema
Nursing responsibility:
> Monitor CBC and platelet counts. Watch out for signs and symptoms of bleeding or
bruising.
> Monitor intake and output. Watch out for fluid retention and edema.
> Assess for irregular heartbeat, unusual bleeding, rash or hives.
Drug: Potassium Chloride
Classification: Mineral, electrolyte replacement, nutritional supplement

MOA: Maintains acid base balance, isotonicity, and electrophysiologic balance

throughout body tissues; crucial to nerve impulse transmission and contraction of
cardiac, skeletal, and smooth muscle. Also essential for normal renal fucnton and
carbohydrate metabolism.
Indication:
> to prevent potassium depletion
> Potassium depletion; diabetic ketoacedosis; metabolic alkalosis; arrhythmias,
periodic paralysis attacks, hyperadrenocortism; primary aldosteronism, healing phase
of sclads or burns, over medication with adrenocorticoids, testosterone or
corticotrophin
Contraindication:
> hypersensitivity to drug
> acute dehydration
> heat cramps
> hyperkalemia
> severe renal impairment
> severe haemolytic reaction
> severe tissue trauma
> esophageal compression caused by enlarged left atrium
> concurrent use of potassium sparing diuretics, angiotensin enzyme converting
inhibitors, or salt substitute containing potassium
Adverse reaction:
> CNS: confusion, unusual fatigue, restlessness, asthenia, flaccid paralysis,
paresthesia, absent reflexes
> CV: ECG changes, hypotension, arrhythmias, heart block, cardiac arrest
> GI: nausea, vomiting diarrhea, abdominal discomfort, flatulence
> Metabolic: hyperkalemia
> Musculoskeletal: weakness and heaviness of legs
> Respiratory: repiratory paralysis
> Other: irritation at IV site
Nursing Responsibility:
> Monitor renal function, fluid intake and output, potassium, creatinine and blood urea
nitrogen levels.
> Asses vital signs and ECG. Stay alert for arrhythmias.
> Monitor neurologic status. Watch for neurologic complications.

> Assess for the presence of adverse reactions.

> Should be used cautiously to patient with severe renal impairment because of
hyperkalemia.
Drug: Sodium Acetate
Classification: electrolyte
MOA : Sodium plays an important role in controlling the total body water and its
distribution. Sodium is the main cation in the extracellular fluid and comprises >90%
of total cations. The acetate component is an alternate source of bicarbonate by
metabolic conversion in the liver.
Indication: an alternative to sodium chloride to provide sodium ion (Na+)
Adverse effects: gastric distension, flatulence; phlebitis; pulmonary oedema;
congestive conditions; dilution of serum electrolytes, over-hydration, hypokalaemia,
metabolic alkalosis, hypocalcaemia;
Nursing responsibility:
> Solutions containing acetate ions should be used with great care in patients with
metabolic or respiratory alkalosis
> Acetate should be administered with great care in those conditions in which there is
an increased level or an impaired utilization of this ion, such as severe hepatic
insufficiency.
>Do not administer unless solution is clear and seal is intact;
Drug: Potassium phosphate
Classification: Mineral, electrolyte supplement
MOA: Phosphorus is involved in many biochemical functions in the body and
significant metabolic and enzyme reactions in almost all organs and tissues; it exerts
a modifying influence on the steady state of calcium levels, a buffering effect on acidbase equilibrium, and a primary role in the renal excretion of hydrogen ion.
Potassium is the principal intracellular cation; it helps transport dextrose across the
cell membrane and contributes to normal renal function.
Indication:

> for addition to large volume intravenous fluids to prevent or correct

hypophosphatemia
Contraindication:
> hyperkalemia
>hyperphosphatemia
> hypercalcemia
Adverse reactions:
> paresthesia of the extremities, flaccid paralysis, listleness, mental confusion,
weakness and heaviness of the legs, hypotension, cardiac arrhythmias, heartblock,
electrocardiographic abnormalities, hypocalcemic tetany
Nursing Responsibility:
> Monitor serum electrolyte levels particularly Ca levels, ECG and renal function
during the course of therapy

Drug: Insulin
Classification: Pancreatic hormone, hypoglycaemic
MOA: Promotes glucose transport, which stimulates carbohydrate metabolism in
skeletal and cardiac muscle and adipose tissue. Also promotes phosphorylation of
glucose in liver, where its converted to glycogen. Directly affects fat and protein
metabolism, stimulates protein synthesis, inhibits release of free fatty acids and
indirectly decreases phosphate and potassium.
Indication:
> Type 1 and type 2 diabetes mellitus unresponsive to diet and oral hypoglycemics
> Diabetic ketoacidosis
Contraindication:
> Hypersensitivity to drug or its components
> hypoglycaemia
Adverse reactions:
> Metabolic: hypokalemia, sodium retention, hypoglycaemia, rebound hyperglycemia
> Skin: urticaria, rash, pruritus
> Other: edema, lipodystrophy, lipohypertrophy; erythema, stinging or warmth at
injection site, anaphylaxis
Nursing Responsibility:
> Monitor glucose level frequently to assess drug efficacy
> Watch blod glucose level closely f patient is converting from one insulin type to
another or is under unusual stress
> Monitor for signs and symptoms of hypoglycaemia.
> Monitor for glycosuria
> Evaluate kidney and liver function test results

PRIORITIZED PROBLEMS WITH JUSTIFICATION

PROBLEMS
1. Deficient fluid
volume related to
active fluid
volume loss

2. Decreased
cardiac output

PRIORITIZATION
The patient experienced hypovolemic shock and had worsening hyperglycemia that hastens osmotic dieresis leading to dehydration, so they had to
intervene by fluid resuscitation, the patient received 20L of intravenous fluids within the 36 hours of hospitalization, and this is because the patient is
severely dehydrated. This is classified under the circulation of ABC in emergency assessment. An article by Robin R Hemphill, MD, MPH; Chief Editor:
Erik D Schraga, MD entitled hypovolemic shock stated that when glycemia reaches approximately 180 mg/dL, proximal tubular transport of glucose
from the tubular lumen into the renal interstitium becomes saturated, and further glucose reabsorption is no longer possible. The glucose that remains
in the renal tubules continues to travel into the distal nephron and, eventually, the urine, carrying water and electrolytes with it. Osmotic diuresis then
results, the loss of water results in further hyperglycemia and loss of circulating volume. Hyperglycemia and the rise in the plasma protein
concentration cause a hyperosmolar state. The hyperosmolarity of the plasma triggers release of antidiuretic hormone, which ameliorates renal water
loss. In the presence of HHS, if the renal water loss is not compensated for by oral water intake, dehydration leads to hypovolemia. Hypovolemia, in
turn, leads to hypotension, which is presented in the case and hypotension results in impaired tissue perfusion. Without this problem being not able to
be resolved, then it will lead now to the next problems below, hence our 1st prioritization.

The patient had a BP of 79/37 which is below normal value and also indicates hypotension. It is caused by hypovolemia. This is also can
be classified as circulation under the concept of ABC assessment because it deals with the blood circulating through the heart which is

related to
hypovolemia

decreased but it can also affect the breathing of the patient. A study by L. I. G. WORTHLEY entitled Shock: A Review of Pathophysiology
and Management. Part I stated that there would be a neural or immediate response that happens when there is low circulating blood
volume. The right atrial and left atrial pressures fall, activating low pressure receptors in the atria and walls of the pulmonary arteries,
great veins and ventricles. With further intravascular blood loss, the reduction in venous return causes a decrease in cardiac output and
blood pressure. In addition, severe hypotension (e.g. MAP of 50 mmHg or less) activates chemoreceptor receptors of the carotid and
aortic bodies; and at a MAP of 40 mmHg or less, a central nervous system ischaemic response occurs. These signals are transmitted to
the vasomotor centre in the medulla and pons, which sends efferent impulses via the sympathetic and vagus nerves to increase the heart
rate, myocardial contractility and peripheral arteriolar and venous tone. If the problem is not resolved, it would lead to another problem
which is ineffective tissue perfusion, hence the 2nd prioritization.

3. Ineffective tissue
perfusion related
to blood loss and
hypotension

This problem is caused by the decreased cardiac output. This fall in the circulation category of the ABC emergency assessment. Because
of the decreased blood volume that causes hypotension and also decreased cardiac output, the perfusion is not enough for the vital
organ like the heart would work/function. An article by Lynn Duane, MSN, RN, TCHP Program Manager entitled Types of Shock presents
the straight forward pathophysiologic process of hypovolemic shock where in blood and/or fluids that have left the body, will cause a
decreased amount of volume in the blood vessels. Venous return is decreased because of the lack of fluid in the vascular space, causing
decreased ventricular filling. The ventricles do not have as much blood as normal to pump out, so the stroke volume is decreased. The
heart rate will increase to compensate for the diminished stroke volume and resulting poor cardiac output and blood pressure.
Eventually, if the fluid or blood loss continues, the heart rate will not be able to compensate for the decreased stroke volume resulting to
inadequate tissue perfusion, hence our 3rd prioritization.

4. Unstable blood
glucose level
increased
resistance to
insulin

The patient glucose level is 2636 which is elevated above normal value.It falls under circulation in ABC assessment concept, because of
persistent dehydration cause by massive fluid loss; it would now cause the blood glucose to rise. A reading from a book by Ellie Whitney,
Linda Kelly DeBruyne, Kathryn Pinna, Sharon Rady Rolfes entitled Nutrition for Health and Health Care under Hyperosmolar
Hyperglycemic Syndrome in Type 2 diabetes, it states there that HHS is a condition of severe hyperglycemia and dehydration that
develops in the absence of significant ketosis. The profound dehydration that eventually develops exacerbates the rise in blood sugar
levels, which often exceed 600 mg/dL and may climb above 1000 mg/dL. Blood plasma becomes so hyperosmolar as to cause
neurological abnormalities such as abnormal reflexes, motor impairements and seizures. The hyperosmolar hyperglycemic syndrome is
sometimes the first sign of type 2 diabetes in older persons. If the problem will not be resolved it may lead to another problem which is
impaired renal function, Hence prioritizing it the 4th.

5. Impaired renal
function related to

Because of the patients unstable blood glucose, there would be an alteration of the liver to function properly. In ABC emergency
assessment, this problem would fall to circulation because it has something also to do with the decreased blood volume that is going

abnormal renal
perfusion

through the kidneys which can impair the renal perfusion thus affecting the renal function. An article entitled Renal Disease in Type 2
Diabetes Media Fact Sheet states that the increase level of blood glucose can damage the kidneys filters. This leaves people with type 2
DM at risk of developing renal impairment. When the kidneys are damaged, the protein albumin leaks out of the kidneys into the urine.
The problem identified is the 5th prioritization.

6. Disturbed thought
processes related
to decreased
cerebral perfusion

The patient has a GCS of 7, Lethargy and Disorientedness caused by decreased tissue perfusion. Under the ABC emergency
assessment, it can fall under the circulation because it has something to do with the decreased blood circulating to the brain .A study by
Phil Zeitler , Andrea Haqq, Arlan Rosenbloom ,Nicole Glaser entitled Hyperglycemic Hyperosmolar Syndrome in Children:
Pathophysiologic Considerations and Suggested Guidelines for Treatment states that the effect of HHS on the brain may differ from that
seen in DKA and this difference must also be considered in planning treatment. Studies of chronic hypertonicity suggest that brain cells
produce idiogenic osmoles, osmotically active substances that preserve intracellular volume by increasing intracellular osmolality.
Patients are thought to be at risk for cerebral edema if the rate of decline in serum osmolality exceeds the rate at which brain cells can
eliminate osmotically active particles. Therefore, in theory, children with HHS, who experience prolonged, persistent hypertonicity should
be at greater risk for cerebral edema via this mechanism than those with DKA, in whom hypertonicity is less severe and of shorter
duration. Recent data suggest that cerebral vasoconstriction due to hypocapnia may be important in the pathogenesis of DKA-related
cerebral edema. Diminished circulatory volume combined with cerebral vasoconstriction may lead to cerebral hypo perfusion with edema
occurring during reperfusion. So, because of the hypoperfusion in the brain there can be an effect in altering the mental health status of
the patient. If this problem cannot be resolved, it can lead to another problem which is the risk for injury hence prioritized as the 6th.

7. Risk for injury

related to altered
level
of
consciousness

This problems falls under the circulation of ABC assessment concept because of the decreased systemic circulation in the brain, there is
also a decreased in perfusion which can present manifestations of altered mental health status like disorientedness and lethargy. This a
potential problem that has not yet occurred, but interventions are directed at prevention, hence the last prioritization

NURSING CARE PLANS

ASSESSMENT
P# Hypovolemic
Shock
S>

O
With a chief
complaint of
altered mental
status
With a history
of
upper
respiratory
symptoms 4-5
days ago
With history
of
diarrhea
and vomiting
for three days
Supplementin
g her diet with
milkshakes
and smoothies
when she was
thirsty
Progressively
weak
and
sleepy

EXPLANATION
OF THE
PROBLEM

GOALS AND
OBJECTIVES
STO>
Within 8 hours
nursing intervention
the patient will
maintain fluid
volume at a
functional level as
evidenced by:

INTERVENTIONS
Dx
Assess
patients
respirations by observing
respiratory rate and depth
and use of accessory
muscles.

a. moist mucous
membrane.
b. good skin turgor.
c. prompt capillary
refill.
d. adequate urine
output at least
30 cc per hour.
Within 8 hours of
nursing intervention
the patient will be
able to
a. increase GCS
from 7 to 9.
LTO
within 72 hours of
nursing

Observe
patient
for
restlessness,
agitation,
confusion and (late stages)
lethargy.

RATIONALE

Increased respiratory rate and use of accessory muscles

may be seen in patients with hypoxia. Factors which
increase respiratory rate are the following: low ph
(acidosis)-via peripheral, high PaCo2 (Hypercapnea)via (mainly) central, peripheral, low PaO2
(hypoxemia)-via peripheral, raised temperature
(hyperthermia)- via peripheral, skin, pain, severe
hypotension-via peripheral, arterial baroreceptor, some
chemical and irritants, exercise- via joint/ muscle
receptor, voluntary control (to limited extent),
Increased elastic recoil and/or lower airway resistance.
Hypoxia is a pathological condition in which the body
as whole (generalized hypoxia) or a region of the body
(tissue hypoxia) is deprived of adequate oxygen supply.
In the latter, the oxygen concentration within the
arterial blood is abnormally low. It is possible to
experience hypoxia and have low oxygen content but
maintain high oxygen partial pressure. Hypoxia also
occurs in healthy individuals when breathing mixtures
of gases with low oxygen content.
Changes in behavior and mental status can be early
signs of impaired gas exchange which will result from
decreased cardiac output. The interference of gas
exchange occurs when the function of a number of
different organs and tissues is impaired. The most
common form of impairment to gas exchange is
hypoxia, which is the lack of oxygen in the tissues.

EVALUATIO
N

 With lethargy
noted
Mild
polydipsia
noted
Some nocturia
over the past
few nights
With
a
paternal
history of type
1 DM
With
a
significant
family history
of obesity
With a GCS
of 7
Vital
signs:
PR: 159 bpm,
RR: 20 cpm,
T:
104.4F
(40.2C), BP:
79/37
With weight
of 65 kg and
BMI was 26
kg/m
(80th
percentile for
age)
Rapid glucose
test
read

interventions, the
patient will be able
to
a. Achieve a
normal sinus
rhythm from
sinus
tachycardia.

Assess for mental status

changes.

Monitor urinary output.

Measure or estimate fluid
losses from all sources
such as gastric losses,
wound
drainage,
and
diaphoresis.

Observe
patient
for
changes in skin color,
moisture, temperature and

Hypoxia can be caused by hypoventilation, diffusion

impairment, shunt, and or ventilation-perfusion (the
rate of ventilation to CO2 production) inequality.
Hypoventilation is the reduced alveolar ventilation in
comparison to the metabolic CO2 production in which
the PCO2 levels increase above normal. It is caused by
disease in the lung or deficits in the respiratory control
pathway from the medulla to the chemoreceptors.
Increasing lethargy, confusion, restlessness and/or
irritability can be early signs of cerebral hypoxia from
decreased cardiac output. Cerebral hypoxia occurs
when there is not enough oxygen getting to the brain.
The brain needs a constant supply of oxygen and
nutrients to function. Cerebral hypoxia may be caused
by: cardiac arrest, cardiac arrhythmia and very low
blood pressure. Brain cells are extremely sensitive to a
lack of oxygen. Some brain cells start dying less than 5
minutes after their oxygen supply disappears. As a
result, brain hypoxia can rapidly cause severe brain
damage or death.
Fluid replacement needs are based on correction of
current deficits and ongoing losses. A decreased urinary
output may indicate insufficient renal perfusion or
hypovolemia, or polyuria can be present, requiring
more aggressive fluid replacement. A large decrease in
urine output may be a sign of a serious, or even lifethreatening, condition. However, urine output can
usually be restored if you get medical treatment right
away. Some causes of decreased urine output may be
blood loss, dehydration and severe infection.

>750mg/dl
Pupils were
equal
and
responsive to
light
Mucus
membranes
were dry
Neck
was
supple
with
no
jugular
venous
distension and
notable
for
acanthosis
nigricans
Decreased
breath sounds
on the right
base
with
some
nasal
flaring but no
significant
respiratory
distress
Cardiac
examination
was consistent
with
sinus
tachycardia
and
no
murmurs

capillary refill time.

Assess peripheral pulses.

TX:
Turn frequently, gently
massage skin, and protect
bony prominences.

Provide safety precautions

such as use of side rails

Collaborative:
Administer IV solutions as
indicated.

Pallor or cyanosis, cool moist skin and slow capillary

refill time may be present from peripheral
vasoconstriction and decreased oxygen saturation.
Some of the possible common medical causes of
decreased oxygen concentration may include:
hypoventilation. Peripheral vasoconstriction may be
caused by hypovolemic shock.
Weak thread, peripheral pulses may reflect
hypotension, vasoconstriction, shunting and venous
congestion. Hypotension is pressure so low it causes
symptoms or signs due to the low flow of blood
through the arteries and veins. When the flow of blood
is too low to deliver enough oxygen and nutrients to
vital organs such as the brain, heart, and kidney, the
organs do not function normally and may be
temporarily or permanently damaged.
Tissues are susceptible to breakdown because of
vasoconstriction and increased fragility (Doenges et al,
2006). Deficient fluid volume decreases tissue
oxygenation, which makes the skin more vulnerable to
breakdown (NA, 2009).
Positioning the patient can also increase
perfusion throughout the body; place the patient in a
modified Trendelenburg's position to facilitate venous
return and to prevent excessive abdominal viscera shift
and restriction of the diaphragm that occurs with the
head-down position (NA, 2011).
Decreased cerebral perfusion frequently results in
changes in mentation/ altered thought processes,

 Pedal pulses
were
minimally
palpable
Abdomen was
obese,
soft
and
nondistended,
with
no
hepatospleno
megaly
Striae
were
present on the
flanks
ABG:
ph:
7.12, PCO2:
500mmHg,
HCO3:
15mM;
PaO2:99mmH
g.
CBC: WBC14.6/uL,
a
Hct: 37% and
Plt:
507,000/uL
Electrolytes:
Na: 137mM,
K: 5.2 mM.
Cl: 102 mM,
Cl: 102mM,
Phosphorus:

- Isotonic

Administer supplemental
oxygen as indicated

Administer
Dopamine
Hydrochloride as indicated

Edx
Encourage patient to drink
increase fluid intake at
least 8 glasses per day as
tolerated.

requiring protective measures to prevent client injury

(Doenges et al, 2006).

Isotonic solutions cause intravascular expansion and

possibly some interstitial edema but no water shifts into
or out of cells (Na, 2000). It helps restore intravascular
volume; this will decrease counterregulatory hormones
and lower blood glucose, which should augment insulin
sensitivity. The initial fluid of choice is isotonic saline
(0.9% NaCl), even in HHS patients or DKA patients
with marked hypertonicity, particularly in patients with
evidence of severe sodium deficits manifested by
hypotension, tachycardia, and oliguria. Isotonic saline
is hypotonic relative to the patient's extracellular fluid
and remains restricted to the extracellular fluid
compartment (Kitabchi et al, 2001).
Since low oxygen levels in blood (hypoxemia) is
among the common signs and symptoms of circulatory
shock, doctors usually recommend oxygen therapy to
the treatment of circulatory shock. Oxygen
supplementation is mandatory in order to lower risking
potential complications that may result from
hypoxemia (NA, 2011). It is also necessary to provide
oxygen support to impending respiratory distress
during shock.
It causes norepinephrine release (mainly on the
dopaminergic receptors), leading to vasodilation of
renal and mesenteric arteries. Also exerts intoropic
effects on heart, which increases the heart rate, blood

4.5 mg.dl
Serum
glucose:
2636mg/dL,
Osmolality:46
6
mOsm/L;
BUN
77mg/dl;
Creatinine:
4.08mg/dl,
Troponin
I:
0.268 ng/ml;
Lactic acid:
7.6mM,
amylase 112
U/L,
Hgb
A1C- 11.5%;
With
Urinalysis
result
of:
3+glucose and
trace ketones
A1> Deficient
fluid volume
related
to
active
fluid
loss
A2>
Decreased
cardiac output
related
to

flow, myocardial contractility, and stroke volume.

Encourage to eat food high

in fluid content such as
watermelon, potato,
pineapple, strawberries
and orange.

Instructed the SO to report

any changes in skin color,
moisture, temperature of
the client.

One reason might be that your blood volume is too low

causing low blood pressure. Low blood pressure can
make you feel light-headed and is dangerous because
you need your blood to be able to deliver oxygen to
your brain and the rest of your body. You can increase
your blood volume and hence your blood pressure by
increasing your fluid intake. Also, when you are
dehydrated your body can become deficient in certain
things such as sodium, potassium,and other
electrolytes.
Pineapple, strawberries and oranges contain some of
the
highest
percentage
of
water.
These will relieves thirst and discomfort of dry mucous
membranes and augments parenteral replacement.
Water balance is achieved in the body by ensuring that
the amount of water consumed in food and drink (and
generated by metabolism) equals the amount of water
excreted. The consumption side is regulated by
behavioral mechanisms, including thirst and salt
cravings.
Pallor or cyanosis, cool moist skin and slow capillary
refill time may be present from peripheral
vasoconstriction and decreased oxygen saturation.
Some of the possible common medical causes of
decreased oxygen concentration may include:
hypoventilation. Peripheral vasoconstriction may be
caused by hypovolemic shock.

decreased
myocardial
contractility
A3>Ineffectiv
e
tissue
perfusion
related
to
decrease
in
the
cellular
components
required for
the delivery of
oxygen to the
cells

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