Susceptible to a condition manifested by failure to perfuse or oxygenate vital organs

• Excessive bleeding
• Factors identified by standardized, validated screening tool
• Hyperthermia
• Hypothermia
• Hypoxemia
• Hypoxia
• Inadequate fluid volume
• Inadequate knowledge of bleeding management strategies
• Inadequate knowledge of infection management strategies
• Inadequate knowledge of modifiable factors
• Ineffective medication self-management
• Nonhemorrhagic fluid loss
• Unstable blood pressure

• Artificial respiration
• Chemotherapy
• Diabetes mellitus
• Digestive system diseases
• Embolism
• Heart diseases
• Hypersensitivity
• Immunosuppression
• Infections
• Lactate levels ≥2 mmol/L
• Medical devices
• Neoplasms
• Nervous system diseases
• Nicotine addiction
• Radiotherapy
• Sequential Organ Failure Assessment (SOFA) Score ≥3
• Simplified Acute Physiology Score (SAPS) III > 70
• Surgical procedures
• Systemic inflammatory response syndrome (SIRS)
• Wounds and injuries

• Cardiovascular status including heart rate and rhythm, blood pressure, peripheral pulses
• Signs of dehydration, inflammation, or allergic responses
• Respiratory status including respiratory rate and depth, pulse oximetry
• Renal status, intake and output, urine specific gravity
• Mental status including orientation, level of consciousness

• Patient will maintain adequate blood pressure to maintain tissue perfusion.
• Patient will not experience hemodynamic complications from underlying medical condition.
• Patient will understand the need for aggressive management of underlying medical condition in an effort to prevent shock.
• Patient will verbalize signs and symptoms of possible hypotension and hypoperfusion.

Suggested NOC Outcomes

• Monitor hemodynamic status frequently, including blood pressure, heart rate, oxygen saturation. Trending of vital signs will provide database for early intervention and treatment.
• Assess level of consciousness with each vital sign check. Change in level of consciousness is an early indicator of cerebral hypoperfusion.
• Administer intravenous fluids, oxygen, and medications as prescribed to maintain fluid volume and organ perfusion.
• Collect and evaluate serum laboratory specimens to provide data to effectively treat underlying medical condition and avoid complication of shock.
• Educate patient and family of reportable signs and symptoms of inadequate tissue perfusion, for example, dizziness, confusion, restlessness, and dyspnea. Early intervention and treatment is essential in preventing permanent organ damage.
• Encourage patient and family to express concerns and fears to reduce anxiety.
• Collaborate with other members of the health care team to effectively manage underlying medical condition and prevent complications.

Suggested NIC Interventions

• Patient's blood pressure was adequate to maintain tissue perfusion.
• Patient did not experience any complications related to hypoperfusion.
• Patient understood the need for aggressive management of underlying medical condition to prevent hypoperfusion.
• Patient was able to verbalize reportable signs and symptoms of possible hypoperfusion and shock.

• Patient's vital signs, intake and output, and laboratory results
• Patient's response to medical interventions to treat underlying condition
• Ability of patient to identify reportable signs and symptoms of hypoperfusion
• Evaluations for expected outcomes

• Enslow, M. S., Preece, S. R., Wildman-Tobriner, B., Enslow, R. A., Mazurowski, M., & Nelson, R. C. (2018). Splenic contraction: A new member of the hypovolemic shock complex. Abdominal Radiology, 43(9), 2375-2383. doi:10.1007/s00261-018-1478-3
• Standl, T., Annecke, T., Cascorbi, I., Heller, A. R., Sabashnikov, A., & Teske, W. (2018). The nomenclature, definition and distinction of types of shock. Deutsches Aerzteblatt International, 115(45), 757-767. doi:10.3238/arztebl.2018.0757
• Xie, Z., Zhang, Z., Xu, Y., Zhou, H., Wu, S., & Wang, Z. (2018). Effects of arm elevation on radial artery pressure: A new method to distinguish hypovolemic shock and septic shock from hypotension. Blood Pressure Monitoring, 23(3), 127-133. doi:10.1097/MBP.0000000000000318