ASSESSM ENT Subjective: Objective: BP: 80/50 Cool, clammy skin Pallor (lips, nail beds of hands and

and feet and conjuncti va) Poor capillary refill Dry mucous membran e Urine output of 30mL/hr

DIAGNOSIS Ineffective tissue perfusion related to loss of circulating volume

PLANNING Short Term Goal: After 4 hours of nursing intervention, the patient will demonstrate: a. Increased bloo

IMPLEMENTATION
Intervention: Independent: Monit or vital signs

EVALUATION

Rationale:
-to serve as a baseline data for trends of subsequent findings. - decreased tissue perfusion is evidenced by the skin becoming pale, cool and moist; as hemoglobin concentrati on occurs, cyanosis occurs - to facilitate venous return and to prevent excessive viscera shift and restriction of the diaphragm that occurs with the head-down position

Monit or skin color, turgor and moist ure

Positi on the client in a Trend elenb urg

positi on

Short Term: Client will demonstrate adequate tissue perfusion AEB blood pressure, pulse rate and rhythm within normal parameters for client; strong peripheral pulses, and ability to tolerate activity without dyspnea, syncope or chest pain, and increased urine output by [date] at 16:00. Long Term: Client will verbalize knowledge of their treatment regimen, including appropriate exercise and medications, their actions and possible side effects by [date] at

Hypotension because it is the most common sign and symptom of hypo shock. Since the first nursing intervention of a nurse when assessing a patient is inspection. And during the initial, compensatory and progressive and irreversible stage, the first sign that will manifest is blood pressure and the verbalization of pt that he or she has a nape pain since during the first stage of hypo shock, the pt is still alert and oriented. Result of hypo shock initially results to decrease stroke volume, CO and blood pressure.