Case Study 10: Hypovolemic Shock
Scenario
The wife of C.W., a 70-year-old man, brought him to the emergency department (ED) at 0430. She
told the ED triage nurse that he had diarrhea for the past 2 days and that last night he had a lot of
“dark red” diarrhea. When he became very dizzy, disoriented, and weak this morning, she decided to
bring him to the hospital. C.W.’s vital signs (VS) in the ED were 70/− (systolic blood pressure [SBP]
70, diastolic blood pressure [DBP] inaudible), pulse rate 110, respiratory rate 22, oral temperature
99.1 ° F (37.3 ° C). A 16-gauge IV catheter was inserted and a lactated Ringer’s infusion was
started. The triage nurse learned C.W. has had idiopathic dilated cardiomyopathy for several
years. The onset was insidious, but the cardiomyopathy is now severe. His last cardiac
catheterization showed an ejection fraction of 13%. He has frequent problems with heart failure
(HF) because of the cardiomyopathy. Two years ago, he had a cardiac arrest that was attributed
to hypokalemia. He has a long history of hypertension and arthritis. He had atrial fibrillation in
the past, but it has been under control recently. Fifteen years ago he had a peptic ulcer.
Endoscopy showed a 25- × 15-mm duodenal ulcer with adherent clot. The ulcer was cauterized, and
C.W. was admitted to the medical intensive care unit (MICU) for treatment of his volume deficit. You
are his admitting nurse. As you are making him comfortable, Mrs. W. gives you a paper sack filled
with the bottles of medications he has been taking: enalapril (Vasotec) 5 mg PO bid, warfarin
(Coumadin) 5 mg/day PO, digoxin (Lanoxin) 0.125 mg/day PO, potassium chloride 20 mEq PO bid,
and diclofenac (Voltaren) 50 mg PO tid. As you connect him to the cardiac monitor, you note he is in
sinus tachycardia. Doing a quick assessment, you find a pale man who is sleepy but arousable and
slightly disoriented. He states he is still dizzy and feels weak and anxious overall. His BP is 98/52,
pulse is 118, and respiratory rate 26. You hear S3 and S4 heart sounds and a grade II/VI systolic
murmur. Peripheral pulses are all 2+, and trace pedal edema is present. Capillary refill is slightly
prolonged. Lungs are clear. Bowel sounds are present, mid-epigastric tenderness is noted, and the
liver margin is 4 cm below the costal margin. Has not yet voided since admission. Rates his pain
level as “2.” A Swan-Ganz pulmonary artery catheter and a peripheral arterial line are inserted.
1. What may have precipitated C.W.’s gastrointestinal (GI) bleeding?
The duodenal ulcer probably precipitated the gastrointestinal (GI) bleeding. These ulcers can
become serious if they perforate because of the risk of hemorrhage.
2. From his history and assessment, identify 5 signs and symptoms of GI bleeding and loss of blood
volume, and explain the pathophysiology for each one listed.
Low blood pressure state in which the arterial blood pressure is abnormally low
Dark red diarrhea blood in stool because of the GI bleeding
Pale skin caused from decreased blood pressure (low circulating blood)
Slightly prolonged capillary refill caused from dehydration and/ or decreased peripheral perfusion
Tachycardia heart beats faster when low circulating blood occurs
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, 3. What is the most serious potential complication of C.W.’s bleeding?
Hypovolemic shock caused by sudden blood loss or decreased circulating blood.
4. Your institution uses electronic charting. Based on the most recent assessment, mentioned
previously, which of these systems would you mark as “abnormal” as you document your findings?
For abnormal findings provide a brief narrative note.
☐ Neurologic: sleepy but arousable and slightly disoriented, patient is slightly dizzy
☐ Respiratory: RR is 28, clear bilateral lung sounds
☐ Cardiovascular: patient is tachycardic with a pulse of 118-cardiac monitor showing sinus
tachycardia, S3 and S4 heart sounds audible with a grade II/VI systolic murmur, BP is low- 98/52,
capillary refill time is delayed
☐ GI: mid-epigastric tenderness is noted, and the liver margin is 4 cm below the costal margin
☐ Genitourinary: patient has not urinated since admission
☐ Musculoskeletal: patient states feeling weak
☐ Skin: pale skin, trace pedal edema present, capillary refill time is delayed
☐ Psychosocial: wife at bedside, patient is anxious
☐ Pain: patient is slightly uncomfortable, rates pain a 2/10
5. What intervention is required to assess his renal function?
I would want to assess his urine output and/or do a bladder scan. I would also want to assess any
tenderness on palpation over the bladder. An intervention required to assess his renal function is
blood work and a urinalysis. I would want to get a GFR, serum creatinine, and a BUN (probably will
be high regardless because of dehydration).
6. Calculate C.W’s mean arterial pressure (MAP) and explain why this measure is important.
C.W’s mean arterial pressure is 67. The normal MAP range is 70-100, so C.W’s is low. The low value
is indicative of decreased perfusion to vital organs (brain, kidneys, heart, lungs, etc.).
CASE STUDY PROGRESS
As soon as you get a chance, you review C.W.’s admission laboratory results.
Chart View
Laboratory Results
Sodium 138 mEq/L (138 mmol/L)
Potassium 6.9 mEq/L (6.9 mmol/L)
BUN 90 mg/dL (32.1 mmol/L)
Creatinine 2.1 mg/dL (185.6 mcmol/L)
This study source was downloaded by 100000841848922 from CourseHero.com on 02-18-2022 12:16:06 GMT -06:00
https://www.coursehero.com/file/64178326/Case-Study-10-Hypovolemic-Shockdocx/
Scenario
The wife of C.W., a 70-year-old man, brought him to the emergency department (ED) at 0430. She
told the ED triage nurse that he had diarrhea for the past 2 days and that last night he had a lot of
“dark red” diarrhea. When he became very dizzy, disoriented, and weak this morning, she decided to
bring him to the hospital. C.W.’s vital signs (VS) in the ED were 70/− (systolic blood pressure [SBP]
70, diastolic blood pressure [DBP] inaudible), pulse rate 110, respiratory rate 22, oral temperature
99.1 ° F (37.3 ° C). A 16-gauge IV catheter was inserted and a lactated Ringer’s infusion was
started. The triage nurse learned C.W. has had idiopathic dilated cardiomyopathy for several
years. The onset was insidious, but the cardiomyopathy is now severe. His last cardiac
catheterization showed an ejection fraction of 13%. He has frequent problems with heart failure
(HF) because of the cardiomyopathy. Two years ago, he had a cardiac arrest that was attributed
to hypokalemia. He has a long history of hypertension and arthritis. He had atrial fibrillation in
the past, but it has been under control recently. Fifteen years ago he had a peptic ulcer.
Endoscopy showed a 25- × 15-mm duodenal ulcer with adherent clot. The ulcer was cauterized, and
C.W. was admitted to the medical intensive care unit (MICU) for treatment of his volume deficit. You
are his admitting nurse. As you are making him comfortable, Mrs. W. gives you a paper sack filled
with the bottles of medications he has been taking: enalapril (Vasotec) 5 mg PO bid, warfarin
(Coumadin) 5 mg/day PO, digoxin (Lanoxin) 0.125 mg/day PO, potassium chloride 20 mEq PO bid,
and diclofenac (Voltaren) 50 mg PO tid. As you connect him to the cardiac monitor, you note he is in
sinus tachycardia. Doing a quick assessment, you find a pale man who is sleepy but arousable and
slightly disoriented. He states he is still dizzy and feels weak and anxious overall. His BP is 98/52,
pulse is 118, and respiratory rate 26. You hear S3 and S4 heart sounds and a grade II/VI systolic
murmur. Peripheral pulses are all 2+, and trace pedal edema is present. Capillary refill is slightly
prolonged. Lungs are clear. Bowel sounds are present, mid-epigastric tenderness is noted, and the
liver margin is 4 cm below the costal margin. Has not yet voided since admission. Rates his pain
level as “2.” A Swan-Ganz pulmonary artery catheter and a peripheral arterial line are inserted.
1. What may have precipitated C.W.’s gastrointestinal (GI) bleeding?
The duodenal ulcer probably precipitated the gastrointestinal (GI) bleeding. These ulcers can
become serious if they perforate because of the risk of hemorrhage.
2. From his history and assessment, identify 5 signs and symptoms of GI bleeding and loss of blood
volume, and explain the pathophysiology for each one listed.
Low blood pressure state in which the arterial blood pressure is abnormally low
Dark red diarrhea blood in stool because of the GI bleeding
Pale skin caused from decreased blood pressure (low circulating blood)
Slightly prolonged capillary refill caused from dehydration and/ or decreased peripheral perfusion
Tachycardia heart beats faster when low circulating blood occurs
This study source was downloaded by 100000841848922 from CourseHero.com on 02-18-2022 12:16:06 GMT -06:00
https://www.coursehero.com/file/64178326/Case-Study-10-Hypovolemic-Shockdocx/
, 3. What is the most serious potential complication of C.W.’s bleeding?
Hypovolemic shock caused by sudden blood loss or decreased circulating blood.
4. Your institution uses electronic charting. Based on the most recent assessment, mentioned
previously, which of these systems would you mark as “abnormal” as you document your findings?
For abnormal findings provide a brief narrative note.
☐ Neurologic: sleepy but arousable and slightly disoriented, patient is slightly dizzy
☐ Respiratory: RR is 28, clear bilateral lung sounds
☐ Cardiovascular: patient is tachycardic with a pulse of 118-cardiac monitor showing sinus
tachycardia, S3 and S4 heart sounds audible with a grade II/VI systolic murmur, BP is low- 98/52,
capillary refill time is delayed
☐ GI: mid-epigastric tenderness is noted, and the liver margin is 4 cm below the costal margin
☐ Genitourinary: patient has not urinated since admission
☐ Musculoskeletal: patient states feeling weak
☐ Skin: pale skin, trace pedal edema present, capillary refill time is delayed
☐ Psychosocial: wife at bedside, patient is anxious
☐ Pain: patient is slightly uncomfortable, rates pain a 2/10
5. What intervention is required to assess his renal function?
I would want to assess his urine output and/or do a bladder scan. I would also want to assess any
tenderness on palpation over the bladder. An intervention required to assess his renal function is
blood work and a urinalysis. I would want to get a GFR, serum creatinine, and a BUN (probably will
be high regardless because of dehydration).
6. Calculate C.W’s mean arterial pressure (MAP) and explain why this measure is important.
C.W’s mean arterial pressure is 67. The normal MAP range is 70-100, so C.W’s is low. The low value
is indicative of decreased perfusion to vital organs (brain, kidneys, heart, lungs, etc.).
CASE STUDY PROGRESS
As soon as you get a chance, you review C.W.’s admission laboratory results.
Chart View
Laboratory Results
Sodium 138 mEq/L (138 mmol/L)
Potassium 6.9 mEq/L (6.9 mmol/L)
BUN 90 mg/dL (32.1 mmol/L)
Creatinine 2.1 mg/dL (185.6 mcmol/L)
This study source was downloaded by 100000841848922 from CourseHero.com on 02-18-2022 12:16:06 GMT -06:00
https://www.coursehero.com/file/64178326/Case-Study-10-Hypovolemic-Shockdocx/
