Case Study: Clinical Deterioration in Hypovolemic Shock (NSB236)

This case study focuses on a 67-year-old patient, Kenneth Bradman, experiencing hypovolemic shock due to a per rectum bleeding, exacerbated by prolonged NSAID use leading to bleeding ulcers. The assessment reveals atrial fibrillation, tachycardia, fluctuating blood pressure, and neurological depression. The essay identifies respiratory distress and cardiovascular instability as priority problems, supported by contemporary research. Nursing interventions include ventilation care, medication administration, and vital signs monitoring, with evaluation based on patient orientation and improved breathing. Psychosocially, the case highlights the importance of communication with the patient's family regarding the patient's deterioration and the need for a patient-centered approach. The case study stresses the importance of clinical reasoning, effective communication, and evidence-based practice in managing hypovolemic shock, including the need for rapid fluid replacement, continuous monitoring, and addressing both physical and psychological needs. Annotated bibliographies provide further research on hypovolemic shock.

Running head: NURSING
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Hypovolemic shock can be considered as a life-threatening condition that results
when one-fifth or twenty percent of body’s fluid (blood) has been lost. Loss of extensive fluid
from the body lead to decreased or impaired function of cardiovascular system (Levy et al.,
2018, p. 78). The heart, in hypovolemic state fails to pump the required volume that
consequentially lead to organ failure (Gulati, 2016, p.187). The hypovolemic shock condition
call for a medical emergency (Carlson & Fitzsimmons, 2019, p.474) as it is acute in nature.
Hypovolemic shock affects older adults and young children (Niaudet & Boyer, 2016, p.839)
very much, more than any other age groups. In this case study, a 67 year old patient named
Kenneth Bradman had a large per rectum bleeding. The case study looks into the problem of
rapid patient deterioration due to hypovolemia. The patient has a history of NSAID use on a
prolonged basis that has caused bleeding ulcers (Sostres et al., 2015, p.684). As a measure,
the patient was given packed RBCs, sodium chloride, fresh frozen plasma and
cryoprecipitate.
In the assessment done in the case study, the patient showed atrial fibrillation with
heart beat up to 100 beats per minute. In the cardiovascular assessment, it was found that the
peripheral body temperature was comparatively reduced and the systolic blood pressure
fluctuated between 105 – 120 mmHg. In hypovolemic shock, the heart is forced to pump a
blood volume more than its normal capacity which it eventually fail to produce at one stroke
volume. The afterload keeps on increasing and resultantly, the heart rate increases. There is a
decrease of left ventricular ejection fraction (Meléndez et al., 2017, p.1637) and this lead to
state of tachycardia (that is heart rate of more than 100 beats per volume) (Mar & Raj, 2019,
p.71). Decreased blood volume and intracellular fluid alters the metabolic and hemodynamic
state of the body drastically. In this state, the vital organs that requires a normal perfusion of
oxygen to function properly, fails to meet up with the safe or normal physiological
functioning (Høiseth et al., 2015, p.43). In this case study, Kenneth has exhibited increased

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heart rate that nears tachycardia (tachycardia happens when the heart rate is more than 100
beats per minute). The other vital symptom exhibited by the Kenneth in hypovolemic state, is
the neurological depression which has hampered the patient’s psychological functioning.
Although the patient shows orientation to place and time but require reorientation at times.
The neuropsychological disturbance is associated with reduced level of consciousness which
is a common symptomatic association in hypovolemia. Although the strength in the arms and
legs are mentioned in the case study to be intact – so the nursing diagnosis can assess and
confirm the reduced level of consciousness, is due to neuropsychological depression but
consciousness has to be checked imperatively, in order to relate to the other aspects
(symptoms) of neuropsychological depression. When the patient at checked at 8.25 hours for
an assessment, The patient condition has greatly deteriorated and the symptoms of
hypovolemia were more pronounced – heart rate was 116 beats/ minute (tachycardia), blood
pressure fallen (hypotension), distressed breathing and lowered oxygen saturation along with
overall ‘disorientation’(Phillips, Gavin & Gelfand, 2016, p.433). Tachypnea, pallor and
reduced level of conscious is associated with the hypovolemic condition and these symptoms
were very sound as Kenneth’s deteriorated further. The deterioration can be due to unchecked
bleeding that has resulted in aggravation of the patient’s hypovolemic signs and symptoms.
After doing the nursing assessment and finding the aforementioned symptoms which
is very indicative of further deterioration, the priority problem is the cardiorespiratory
problem. The cardiorespiratory problem has presented with an array of symptoms. The
general, cardiovascular, respiratory and neurological observation assessments has to be
performed. The patient is currently suffering from respiratory distress, resulting due to
underlying pathophysiology of tachypnea and tachycardia (Merlin, Hoy & Rodrigo-Mocholi,
2017, p. e000497). The cardiopulmonary complication is a clinical priority as it is the most
acute and severe symptom presented in Kenneth’s case due to further deterioration and it is of

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utmost importance from the nursing point of view or perspective of clinical care. The labored
breathing which Kenneth is currently suffering from, poses the greatest threat to his clinical
status. Hindrance to respiratory process and further deterioration in the cardiopulmonary
status, would simulate cyanosis and further complication in the hypovolemic status of the
patient. After using the clinical reasoning cycle, a registered nurse can suspect an unchecked
internal bleeding that might have led to this clinical deterioration of patient’s symptoms,
causing further aggravation of patient’s hypovolemic symptomatology. The clinical priority
is to manage the severe cardiopulmonary symptoms associated with the deteriorated
hypovolemic state of the patient. The aggravated clinical presentation of Kenneth is chiefly
due to the worsened cardiovascular function, lowered blood pressure, lowered oxygen
perfusion and disturbed ventilation- perfusion ratio that has led to labored breathing. This has
caused the pallor, peripheral hypothermia and overall disorientation. The clinical priority in
nursing care of Kenneth is to better the cardiovascular and respiratory status of the patient,
otherwise the deterioration might progress to a much irreversible health situation. Prioritizing
the problem is a major clinical challenge as the choice has to be the most complicated
symptoms which affects the condition or progression of the disease in a very adverse way. It
is important to use the clinical reasoning cycle to full effect. In this case, the nurse should use
clinical reasoning cycle, critical thinking in order to prioritize the cardiopulmonary symptoms
above other symptoms and with appropriate nursing care, this problem has to be addressed at
first.
The nursing care of hypovolemic care must manage these three stages (1)
compensated (2) decompensated (3) irreversible (van der Ster et al., 2018, p. e13895). The
trauma care unit or the emergency unit where the patient is admitted, needs to take act fast
with the rehydration and transfusion procedures in order to balance the lost amount of blood
from the body. A series of investigative and diagnostic procedure should follow where blood

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testing, vital signs and general assessments along with cardiovascular, respiratory and
neurological assessments are to be done. In hypovolemic shock, the major functions are
suppressed and the acute nursing care becomes a very integral part of the hypovolemia
management (Mistry et al., 2016, p.263). While nursing assessments are as important to
medical assessments – care must be taken by the nursing practitioners to communicate with
the patient continuously in order to keep him awake as because loss of consciousness can
prove dangerous in these given circumstances. Rapid communication during nursing transfers
is very important and effective communication technique has to be used during the rapid fluid
replacement procedure in hypovolemic shock. The evidence based practice guidelines must
be strictly followed. The first nursing intervention which should be cardinally applied in this
case is a ventilation care (due to respiratory distress) and promoting sleep and relaxation in
the patient plus re-educating the effective breathing pattern is an important measure. This
intervention is solely related to pharmacological agent. Administering the prescribed
medication, at right time to treat hypotension is critical. For the cardiovascular component of
the presenting cardiopulmonary problem – a through vital signs monitoring will be an
important part of second nursing intervention. While positioning of the patient is very much
vital so as to prevent the formation of edema – fluid replacements needs to be done hourly
with appropriate nursing of Kenneth. Keeping the patient oriented by continuously talking to
him, by addressing his name is important. But primarily though, any signs of internal
hemorrhage or external hemorrhage has to be done as well (Tsetsou et al., 2017, p.23). The
efficacy of the nursing interventions will be evaluated by the fact that the patient in the case
becomes more oriented to the environment and the labored breathing returns back to normal.
Hence, nursing interventions should include regular respiratory, CVS and neurological and
cognitive assessments to evaluate the prognosis (de Carvalho Pacagnella & Borovac-
Pinheiro, 2019, p.11).

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Psychosocially, as the patient is going through a critical phases of hypovolemia.
Communication with the family members of Kenneth regarding the rapid deterioration of the
patient symptoms is a huge psychosocial issue as the delivered medical and nursing care
missed some aspects of monitoring if any bleeding may have happened again. This issue
depicts a ‘clinical gap’ between the treatment delivered and the treatment missed. While the
patient condition has become rapidly adverse in a very short period of time – it remains a
huge challenge for the nursing team to communicate effectively with the patient’s family
regarding the same. Care has to be taken about patient autonomy, family centered and patient
centered nursing care and in order to devise a proper family support framework to plan the
further treatment. At first, the nursing principles such as beneficence, non-maleficence,
totality and patient commitment is very important that a RN should comply with while
servicing Mr. Kenneth towards a better prognosis. The condition has presented itself at its
most critical and emphasizing with family’s mindset is the most crucial part of patient and
family- nursing communication (Gausvik et al., 2015, p.33). Miscommunication or hiding the
information about patient’s clinical deterioration from the members of his family can be very
misleading and can evoke legal psychosocial issue as well. Hence, imparting the same
information of what might have happened that we are still suspecting, is the first step to build
a rapport with patient’s family. Strengthening the family network towards the treatment of
Kenneth is an important.
A planned nursing care with principles of beneficence, totality and non-maleficence is
very important. Hypovolemic shock compromises the physiological functioning of the human
body and leads to severe deterioration of the patient’s state. Hypovolemic state generally
results from a traumatic injury that has caused a lot of blood loss and led to decreased blood
volume inside the body. Hence, it can be concluded saying that the right nursing interventions
starts with the right clinical reasoning while doing the nursing assessments and diagnosis. A

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sound communication skill from a nursing perspective is critical to the treatment of the
patient and as shown in this case, a sound clinical reasoning is a must. Hypovolemia is a
clinical state where deterioration can be very rapid, as revealed by this case and hence, care
has to be taken while communicating the same problem to the patient’s family.
Annotated bibliography
Article name – Assessing and managing hypovolemic shock in puerperal women
Author name – Rodolfo Carvalho Pacagnella and AndersonBorovac-Pinheiro
Link - https://www.sciencedirect.com/science/article/pii/S1521693419300574
This study focuses on the post- partum hemorrhage leading to hypovolemic shock and
the resultant reactions of the body in response to the shock. The article highlights the vascular
changes and the pressure changes in the body after an episode of substantial blood loss due to
post-partum hemorrhage. The study focuses on the importance of interventions like oxygen
therapy, volume replacement, fluid resuscitation as important measures to treat the
hypovolemic shock condition.
Article name – Vascular Endothelium and Hypovolemic Shock
Author name – Gulati, Anil
Link - https://www.ingentaconnect.com/content/ben/cvp/2016/00000014/00000002/art00011
This study focuses on the cellular pathophysiology of endothelium damage and how
the basic cellular structures such as mitochondria and substances like reactive oxygen species
are involved in affection of cellular respiration resulting from hypovolemia. The study
focuses on endothelial function and related pathology in response to hypovolemia and

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impaired vascular regulation. The study identifies the risk factors leading to hypovolemia and
related cases of reparative processes and the nursing measures to prevent the same.
Article name – Frequency of left ventricular end-diastolic volume–mediated declines in
ejection fraction in patients receiving potentially cardiotoxic cancer treatment
Author name - Meléndez, G. C., Sukpraphrute, B., D'Agostino Jr, R. B., Jordan, J. H., Klepin,
H. D., Ellis, L., ... & Weaver, K. E
Link - https://www.sciencedirect.com/science/article/abs/pii/S0002914917301947
This article discusses the potential effects of left ventricular end diastolic
volume in terms with reduced left ventricular ejection fraction in hypovolemic shock and the
relation between frequency of left ventricular volumes decrease and the cardiovascular
treatments. The study emphasizes deeply on the aspects of LVEF and its pathophysiology
leading to pronounced hypovolemia and its severe consequences. The influences are drawn in
relation with cardio toxic chemotherapy and cardio vascular magnetic resonance imaging.
Article name – Tissue Oxygen Saturation and Finger Perfusion Index in
Central Hypovolemia
Author name – Høiseth, L. Ø., Hisdal, J., Hoff, I. E., Hagen, O. A., Landsverk, S. A., &
Kirkebøen, K. A
Link
-https://journals.lww.com/ccmjournal/Abstract/2015/04000/Tissue_Oxygen_Saturation_and_
Finger_Perfusion.4.asp

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The study determines on the effect of temperature on the level of pain felt,
tissue oxygen saturation and on the levels of perfusion index and its association in the state of
hypovolemia. The study found out that the pain perception, the tissue oxygen perfusion and
also the perfusion index overall is reduced by the state of hypovolemia. The research study
emphasizes on the sympathetic impairment in relation with the state of hypovolemia. Hence,
according to study – the level of pain perceived in hypovolemia has to be considered as a
clinical sign and indication. This is referred to as an important indication in nursing diagnosis
of hypovolemia.
Article name – Corticosteroids in the Management of Hyponatremia, Hypovolemia, and
Vasospasm in Subarachnoid Hemorrhage: A Meta-Analysis
Author name – Mistry, A. M., Mistry, E. A., Kumar, N. G., Froehler, M. T., Fusco, M. R., &
Chitale, R. V
Link - https://www.karger.com/Article/Abstract/446251
This research study focuses on the importance of the pharmacological
measure used in addressing hypovolemia and hyponatremia in the cases of hemorrhage. In
sub anarchoid hemorrhage – there is an extensive loss of blood and this leads to severe
hypovolemic presentation. The study runs a literature search across the electronic database
such as PubMed, Embase, and Cochrane in order to study the observational, randomized
control trials and found out the importance of corticosteroids on the in treatment of
hyponatremia and hypovolemia.

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Article name - Severe Mitral Regurgitation in Hypovolemic Shock Masquerading as Mitral
Valve Perforation
Author name – Phillips, C.T., Gavin, M.C. and Gelfand, E.V.,
Article link – https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/
2500066
The article focusses on fluid volume shifts in the body due to acute renal failure and
the impairment of the glucose level. The compromised heart function to the same is
emphasized throughout the study and the overall physiological shock, deteriorating the
functions of the body is described. The study emphasizes on fluid resuscitation as an
important measure to the situation.
Article name – Shock, sepsis, and multiple organ dysfunction syndrome.
Author name – Beyer, J., Harrington, D., Herron, H., & Whitaker, T. J
Article link – https://www.ncbi.nlm.nih.gov/pubmed/11354295
The study focusses on the pathogenesis of shock, sepsis and dysfunctional syndrome
in the patients. The intricacies of the mediators and the neuro chemicals involved in the rapid
spread of the hypovolemic and septic shock has been emphasized in this research study. The
nursing management and the medical management should be symptomatic based on the
situation but should always treat the cardinal cause of the presenting symptoms.
Article name – Postural Orthostatic Tachycardia Syndrome: Mechanisms and New Therapies
Author name – Mar, P. L., & Raj, S. R.

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Article link – https://www.annualreviews.org/doi/abs/10.1146/annurev-med-041818-011630
In this study, the conditions such as autonomic neuropathy, hyper-adrenergic state and
hypovolemia has been stressed upon. The underlying pathology of hypovolemic Postural
Orthostatic Tachycardia Syndrome has been studied and the effect of various medications
such as beta blockers, nor-epinephrine re-uptake inhibitors has been focused as well.

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hypovolemic shock in puerperal women. Best Practice & Research Clinical Obstetrics
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Gausvik, C., Lautar, A., Miller, L., Pallerla, H., & Schlaudecker, J. (2015). Structured nursing
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efficiency, understanding of care plan and teamwork as well as job satisfaction.
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(2015). Tissue oxygen saturation and finger perfusion index in central hypovolemia:
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