Hypovolaemic shock r/t bowel obstruction
Debriefing/Guided Reflection
Condition Overview:

Hypovolaemia occurs when loss of extracellular
fluid volume exceeds the intake of fluid. It occurs
when water and electrolytes are lost in the same
proportion as they exist in normal body fluids, so
that the ratio of serum electrolytes to water remains
the same.

Hypovolaemia should not be confused with
dehydration, which refers to loss of water alone with
increased serum sodium levels.

Hypovolaemia may occur alone or in combination
with other imbalances. Unless other imbalances
are present concurrently, serum electrolyte
concentrations remain essentially unchanged.
Causes:
Hypovolaemia results from loss of body fluids and
occurs more rapidly when coupled with decreased fluid
intake. Causes include abnormal fluid losses such as
those resulting from diarrhoea, GI suctioning, sweating,
and decreased intake, as in nausea or inability to gain
access to fluids.
Causes also include third-space fluid shifts, movement
of fluids out of the vascular system (trauma), or oedema
formation resulting from burns, or ascites resulting from
liver dysfunction.
Signs and symptoms:

Acute weight loss, weakness,

Decreased skin turgor

Oliguria, Concentrated urine, increased BUN
creatinine

Postural hypotension, Weak, rapid heart rate

Flattened neck veins

Increased temperature

Cool, clammy skin, muscle weakness and cramps
Management of care—nursing interventions include:
Three goals exist in the emergency treatment of the
patient with hypovolemic shock as follows: (1) maximize
oxygen delivery - completed by ensuring adequacy of
ventilation, increasing oxygen saturation of the blood,
and restoring blood flow, (2) control further fluid loss,
(Simulation in Nursing Education)
Scenario
Estimated scenario time:
15 minutes
Guided reflection time:
15 minutes
Target group:
year 3 nursing students
Brief summary:
This case is a 45 year old male patient to a surgical
ward in your hospital for acute appendicitis 48 hours
ago. An acute appendectomy was performed and the
client has failed to gain normal bowel sounds after the
surgery. He is now complaining of abdominal pain,
inability to pass flatus, and dizziness. The student will
be expected to follow the standard protocols for the
treatment of hypovolaemic shock.
LEARNING OBJECTIVES:
General:

Identifies the primary nursing diagnosis (fluid
volume deficit R/T fluid shifts in bowel obstruction)

Implements risk assessment—what kinds of shock
could this be? Hypovolaemic, septic, cardiogenic?

Implements patient safety measures

Evaluates patient assessment information including
vital signs, pain, and abdominal assessment

Implements therapeutic communication with team
and in ISBAR format

Demonstrates effective teamwork

Prioritises and implements doctors instructions
appropriately
Scenario specific:

Tips bed into reverse trendelenburg to ↑BP

Shows ability to identify appropriate assessments
which may help with differential diagnosis (e.g.
abdominal assessment, fluid volume assessment)

Able to begin volume resuscitation (either 2L .9NS
or 500ml colloid with recheck of BP for effect

Initiates check of fluid balance for last 24 hours
AUT S1 2014
Report to student
Patient Overview:
Thomas Jones is a 45-year-old male developed RLQ
abdominal pain about a week ago which waxed and
waned. About 72 hours ago the pain became acute and
sharp and he presented to the emergency department
where acute appendicitis was diagnosed. He
underwent an acute appendectomy 48 hours ago, at
which time surgeons discovered that his appendix had
ruptured. It was removed, his abdomen flushed, and he
was sent to your ward for recovery.
Patient data:
male, age 45 years, weight 78Kg, height 1.75 metres
DOB:
19-07-XX
Hospital ID number:
987654
Past medical history:
Thomas has a history of a broken arm as a child,
tonsillectomy at age 13. He is not currently on any
medications except vitamins and has no allergies.
Recent medical history:
Has been really ‘pushing’ himself lately and feels the
‘stress’ is starting to get to him. He went out for dinner 3
nights ago and found he was so unwell he was having
difficulty eating or drinking. He was having nausea and
acute RLQ pain at this time.
and (3) fluid resuscitation. Also, the patient's disposition
should be rapidly and appropriately determined.

Obtaining lab values:
o Serum urea, serum creatinine: Volumedepleted individuals show serum urea
elevated out of proportion to the serum
creatinine level (ratio greater than 20:1).
o Haematocrit higher than normal as RBCs
suspended in decreased volume.
o Monitor K+ and Na+ levels as they may be
reduced or elevated.

Two large-bore IV lines should be started.

Fluid balance every 4 hours with vital signs hourly

Assess daily weights and record

Skin turgor and mucous membrane assessment
q8hrs

Administer fluids or plasma expanders to replace
fluids lost or shifted into intravascular space

Place bed in reverse trendelenburg position until BP
is up over 100 systolic, then flat until boluses
completed and BP stable at over 120 systolic.
Hypovolaemic Shock - Resources
Equipment checklist
Equipment to have in the room for this scenario:

Standard precautions equipment

Stethoscope

Blood pressure cuff

SpO2 monitor and probe

Thermometer

ECG monitor and leads

Oxygen supply source

Oxygen delivery devices (nasal cannula, mask, and
ambu bag)
Medication and fluids:

Normal saline 1000ml infusing at 75ml/hour

Tramadol 50-100mg po prn pain

Maxalon 10mg po prn for nausea
Documentation forms:

Doctors instructions/DHB protocols

Observation record, medication sheet, nursing
notes

Fluid balance chart
Diagnostic equipment:

Nursing Anne:

Location: Surgical ward

Dress Anne in male clothing

Lying down in bed

Secure ID band with patient name, DOB, and
hospital ID number

Student performance objectives










Wear gloves
Identify patient name from ID band (DOB, hospital
ID number)
Ask client what prompted him to ring bell
Obtain BP, pulse, RR, Temp, SpO2
Place client in trendelenburg
Assess pain utilising pain scale
Do abdominal assessment
Administer bolus IV fluids
Monitor vital signs every 2-5 min.
Call Registrar with ISBAR report at end of scenario
Number of participants:

1 student—recorder and calling ISBAR ROLE

1 student—doing primary assessment, giving
medications

1 student—Vital signs and airway management

1 student—play family role to improve team
communication
Potential nursing problems
Acute pain related to bowel obstruction
Defining characteristics:

Verbal report

Changes in BP, resp. rate, AP
Fluid volume deficit R/T fluid shifts in bowel
obstruction

Abdomen hard to palpation

Fluid balance In=2100ml Out=300ml last 24 hours

Postural hypotension shift of > 20 beats in pulse,
and drop of 20 systolic points in BP when sitting
Pain r/t increasing abdominal girth and lack of
bowel sounds

Abdominal girth increasing 20cm in last 4 hours

Pain 8-9/10 with no relief with medication
Hypovolaemic Shock - Scenario
SIM MAN settings
Patient/manikin actions
Initial state (0-2 min.)
Lung sounds: clear bilaterally
Heart rate: 140/minute
Abdomen: distended and hard
Respiratory rate: 24/min.
BP: 100/70
SpO2: 97%
Hypovolaemia trend:
HR: 160/min.
Resp. rate: still 24/min.
Student should do the following:

Wear gloves
BP: 90/50
Resp rate: 24/min.
Cue: if student does not look at
abdomen say, “My stomach is hurting so
bad I can hardly stand it. They gave me
something last night but nothing since
about 10pm”

Obtain vital signs & assess pain and
abdomen

Ask client if passing flatus or stool

Last pain medication

Do abdominal assessment
Vocal sounds: “The pain is ‘10’ out of 10
now.’ I think there are black spots in front
of my eyes. What is happening?”

Take vital signs, note trending in BP
and pulse

Report values to recorder
Vocal sounds: Eyes roll back and client
groans. Patient becomes unconscious.

Place bed in trendelenburg

Give fluid bolus of 1 Litres .9NS

Continue to take vital signs every 1-2
minutes to monitor effect of fluid
bolus

Continue to monitor vital signs every
2 minutes and report to recorder
Role member to provide cue: primary
care provider

Communicate therapeutically with
patient
Cue (final orders):

Transfer to ICU

Monitor and record vital signs (BP,
AP, SpO2,) every 2 minutes


CALL ISBAR to physician requesting
further orders
Vocal sounds: “It feels like my abdomen
is a block of cement. The pain is ‘8!’”
Rates pain as ‘8’ on scale of 1-10
SpO2: to 97%
Heart rate: 90/min.
Role member providing cue: patient
Identify patient and introduce self
BP: 70/40
9-12 minutes
Cue/prompt

Temp. 37 C
3-6 minutes
Student interventions
Vocal sounds (after saline bolus):—“I feel
a little better now.”
Role member to provide cue: patient
Cue: if nurse does not act, patient will
say, “All I see are black spots! Please do
something!”
Call when blood results are available
(Troponin-T, CK-MB, Myoglobin),
BUN, creatinine, and HCT/HGB