COLLABORATIVE DIAGNOSIS: Potential complications

  1. hypovolemic shock related to:
    1. hemorrhage associated with opening of wound (can occur as a result of inadequate wound closure, stress on incision line, and/or poor wound healing), slippage of closures on ligated vessels, and/or disruption of clots at incision site
    2. fluid volume deficit associated with restricted oral intake and excessive fluid loss;
  2. atelectasis related to shallow respirations, stasis of secretions in the alveoli and bronchioles, and decreased surfactant production (results from inadequate deep breathing and changes in regional blood flow in the lungs);
  3. thromboembolism related to:
    1. venous stasis associated with decreased activity, positioning during and following surgery, increased blood viscosity (can result from fluid volume deficit), and abdominal distention (the distended intestine may put pressure on the abdominal vessels)
    2. hypercoagulability associated with increased release of tissue thromboplastin into the blood (occurs as a result of surgical trauma) and hemoconcentration and increased blood viscosity (can occur as a result of fluid volume deficit)
    3. trauma to vein walls during surgery;
  4. paralytic ileus related to manipulation of intestines during abdominal surgery, depressant effect of anesthesia and some medications (e.g. narcotic [opioid] analgesics, some antiemetics) on bowel motility, hypokalemia, and hypovolemia (can cause decreased blood supply to the intestine);
  5. dehiscence related to:
    1. inadequate wound closure
    2. stress on incision line associated with persistent coughing, distention, or vomiting
    3. poor wound healing associated with decreased tissue perfusion of wound area, inadequate nutritional status, and infection.
Desired Outcome
The client will not develop hypovolemic shock as evidenced by:
  1. usual mental status
  2. stable vital signs
  3. skin warm and usual color
  4. palpable peripheral pulses
  5. urine output at least 30 ml/hour
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report excessive bleeding and gastrointestinal and wound drainage, persistent vomiting, and/or difficulty maintaining intravenous or oral fluid intake as ordered.
  2. Monitor RBC, Hct, and Hb levels. Report decreasing values.
  3. Assess for and report signs and symptoms of hypovolemic shock:
    1. restlessness, agitation, confusion, or other change in mental status
    2. significant decrease in B/P
    3. postural hypotension
    4. rapid, weak pulse
    5. rapid respirations
    6. cool skin
    7. pallor, cyanosis
    8. diminished or absent peripheral pulses
    9. urine output less than 30 ml/hour.
  4. Implement measures to prevent hypovolemic shock:
    1. if bleeding occurs, apply firm, prolonged pressure to area if possible
    2. perform actions to prevent fluid volume deficit (see Diagnosis 4).
  5. If signs and symptoms of hypovolemic shock occur:
    1. place client flat in bed with legs elevated unless contraindicated
    2. monitor vital signs frequently
    3. administer oxygen as ordered
    4. administer blood and/or volume expanders if ordered
    5. prepare client for insertion of hemodynamic monitoring devices (e.g. central venous catheter, intra-arterial catheter) if indicated.