About
Decrease in intravascular fluid by up to 30%; Hemorrhage, rapid blood loss.
Assess
Bleeding, hemorrhage, severe hypotension, tachycardia, cool extremities, weak peripheral pulses
Complications
Multiple organ dysfunction syndrome, Cardiac arrest, respiratory arrest, death
Diagnosis
- Fluid volume deficit related to blood and fluid loss.
- Acute confusion related to decreased oxygen supply.
- Impaired gas exchange related to decreased oxygen carrying cells.
- Risk for injury related to massive blood loss.
- Impaired tissue perfusion related to decreased cardiac output.
Goals
- The client will not have evidence of bleeding.
- The client will have a stable hemoglobin, hematocrit, electrolytes.
- The client will have a blood pressure within a normal range.
- The client will have adequate circulation evidenced by positive peripheral pulses and warmth.
- The client will maintain a pulse oximetry of greater than 90%.
- The client will remain free from injury.
Interventions
- Assess and monitor frequently ( every 15 minutes- 4hours) vital signs, pulse oximetry, telemetry, CBC, electrolytes.
- Notify physician if sudden drop in blood pressure, hemoglobin, hematocrit, pulse-oximetry and evidence of active bleeding.
- Administer fluids and blood products as ordered.
- Administer vasopressors, antiemetics, antidiarrheals as ordered to prevent excess fluid loss and maintain homeostasis of fluid status.
- Reorient patient frequently, monitor risk for injury.
- Implement safety precautions to prevent injury.
- Administer oxygen as ordered.
- Reposition client in reverse trendelenburg for significant blood pressure drops.
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