NURS 3552 UWORLD NCLEX-RN 2024 RATIONALES

Hypovolemic shock most commonly occurs from blood loss but can occur in any condition that reduces intravascular volume. Hypovolemia is classified as either an absolute (ex. hemorrhage, surgery, gastrointestinal bleeding, vomiting, diarrhea) or a relative (ex. pancreatitis, sepsis) fluid loss. Reduced intravascular volume results in decreased venous return, decreased stroke volume and cardiac output, inadequate tissue perfusion, and impaired cellular metabolism. Clinical manifestations of hypovolemic shock are associated with inadequate tissue perfusion and include: • Change in mental status • Tachycardia with thready pulse • Cool, clammy skin • Oliguria • Tachypnea Decreased urine output (0.5 mL/kg/hr) despite fluid replacement indicates inadequate tissue perfusion to the kidneys and is a manifestation of hypovolemic shock in a client with normal renal function Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on a partial thromboplastin time (PTT). The therapeutic PTT target is 1.5-2.0 times the normal reference range of 25-35 seconds. A PTT value 100 seconds would be considered critical and could result in life- threatening side effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestinal bleeds. A normal hematocrit for a female is 35%-47% (0.35-0.47). In a client with a history of chronic anemia, a hematocrit of 30% (0.30) may be an expected finding. A normal platelet count is 150,000-400,000/mm3 (150-400 x 109/L). In a client with a history of liver cirrhosis, a platelet count of 80,000/mm3 (80 x 109/L) would be anticipated. An episode of bleeding rarely occurs with a platelet count 50,000 mm3 (50 x 109/L). A normal prothrombin time is 11-16 seconds, and so a level of 11 seconds would not be concerning. Heparin infusions require close monitoring by the nurse. The partial thromboplastin time is the laboratory value required to accurately monitor the therapeutic effects of heparin.