A client who has been burned 20% of her body is at high risk for hypovolemic shock. Hypovolemic shock is a life-threatening condition that occurs when the body does not have enough blood or fluids to function properly.
The nurse’s assessment findings of a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats per minute, and a urine output of 25 ml over the past hour are all consistent with hypovolemic shock.
Reporting Findings to Physician
The nurse will report the assessment findings to the physician immediately. The physician will likely order additional tests, such as a blood test to assess the client’s fluid and electrolyte levels.
Anticipating Physician Orders
The physician will likely order aggressive fluid resuscitation to treat the client’s hypovolemic shock. This may involve administering intravenous fluids, such as lactated Ringer’s solution, through a large-bore intravenous catheter. The physician may also order blood transfusions if the client’s blood count is low.
Other Physician Orders
In addition to fluid resuscitation, the physician may also order other medications and treatments to support the client, such as:
- Vasopressors to increase the client’s blood pressure.
- Pain medication to manage the client’s pain.
- Antibiotics to prevent infection.
- Nutritional support to ensure that the client is getting enough nutrients to heal.
The nurse should anticipate that the physician will order aggressive fluid resuscitation for the client with hypovolemic shock. The nurse should also be prepared to implement other physician orders, such as administering medications and providing nutritional support.
The nurse should closely monitor the client’s response to fluid resuscitation. The nurse should monitor the client’s vital signs, urine output, and mental status. The nurse should also assess the client’s skin for signs of fluid overload, such as edema (swelling).
If the client does not respond well to fluid resuscitation, the physician may need to consider other interventions, such as mechanical ventilation or renal dialysis.