NUR2203 Acute Care Across the Lifespan A
ASSESSMENT CRITERIA: Written Assessment
Table of contents:
Table of contents: 2
Solution 1. 2
Solution 2. 4
Solution 3. 6
Solution 4. 6
References 10
Solution 1.
The pathophysiology of hypovolemic shock in the present case scenario states that it is caused due to reduction in intravascular volume due to loss of extracellular fluid or blood. The decrease in the volume of circulating blood is referred to as hypovolemia. Hypovolemia have the tendency to reduce the filling pressure as well as the heart rate (HR) to below the normal values which are required for maintaining perfusion of tissue in the body, the condition is referred to as shock. The low blood pressure causes neuroendocrine response through the ANS (autonomous nervous system), which causes release of hormones such as adrenaline and noradrenaline inside the circulation and leads to increase in cardiac contraction, HR while promoting vasoconstriction. The process is triggered by receptors such as baroreceptors as well as receptors of vascular stretching under low pressure. It causes stimulation of renin-angiotensin system, hence producing angiotensin II, which is a potential vasoconstrictor, while stimulating the aldosterone secretion hence, promoting the water as well as salt conservation. The increase in adrenergic activity also contributes towards the organ flows such as brain, myocardium, etc (Piras, 2017). Due to fall in BP at an relevant low level, coronary flow of blood also gets reduced hence decreasing the ability of the heart muscle to contract and further decreasing DC causing the severe condition of the shock (Suess & Pinsky, 2015). Hypovolemic shock have its effect on several body systems along with cellular degradation such as low transport of sodium as well as potassium between the membrane of the cell, low mitochondrial activity, dysfunctioning of lysosomes, production of hydrolases as well as cell injury. It further affects the cellular metabolism of nutrients by decreasing the activity of glucose and insulin (McNeer & Varon, 2013).
The case study of Eleanor suggested that the patients who undergoes a right hemicolectomy for a poorly differentiated adenocarcinoma of the ascending colon might be presented with extreme loss of fluid as well as electrolytes due to inadequate fluid therapy leading to low range of hemoglobin 78g/L, Red cell count (RCC) 3.8 × 10 (12)/l, Haematocrit (HCT) 0.36 as observed in the patient’s pathology. In the initial 24 hours postoperative phase the abnormal heart rate i/e., HR 106 and low blood pressure i.e., BP 90/54, were also observed. Surgical complications postoperative such as ileus, and sepsis might further create complication in managing the fluid and electrolyte. Under such circumstances, the need of systemic fluid might be high while loss in gastrointestinal fluid can be observed. However, the complications which will arise due to overloading of fluid might be delayed and are unrecognizable within 24 hours of surgery. The irrational as well as the use of fluid boluses for the management of hypertension and low urine output as observed i.e., 15-20 ml/hr is the cause of concern and might lead to excessive fluid balance. The situation of shock might also be due to atrial fibrillation as well as myocardial infarction (MI) as Eleanor have a past medical history of MI with left coronary artery stenting. The factors such as hyperlipidaemia which is caused due to increase in the level of lipids due to high level of cholesterol through hypercholesterolemia, and hypertension can also contributes in increasing the risk of stroke. Some other factors contributing to postoperative stroke includes, old age as Eleanor is 58 years old woman, asthma, smoking (she smokes for about 10 cigarettes a day and alcohol consumption of about 2 units/day. The practice of restrictive IV therapy and medications and their effect on vasopressors might raise concerns regarding the systemic hypertension as well as decreased blood flow in colon. The sedation score of the patient i.e., 1 depicts the feeling of anxious or restlessness which might be due to hypertension (Patel, Panchagnula, Lutz & Bansal, 2012).
The body might compensates for this physiologically with the help of increasing sympathetic tone which will leads to increase in the heart rate, cardiac contraction as well as vasoconstriction towards the peripheral end. The initial changes which are observed in the vital signs at the time of hypovolemic shock consists of increase in the blood pressure towards the diastolic end along with narrowing of pulse pressure. Due to the reduction in volume status there is a drop in systolic blood pressure as well due to which the delivery of oxygen towards vital organs is not able to maintain the demand of oxygen as per the requirement. As a result of which, the cells tends to switch their metabolism from aerobic to anaerobic causing lactic acidosis. However, due to increase in sympathetic drive, the flow of blood flow is consequently diverted from different organs for preserving the flow of blood towards heart and brain. Such event results in tissue ischemia and hence, leads to worsensening of lactic acidosis. Furthermore, the event if not prevented might leads to worsening the hemodynamic compromise resulting in death (Noel-Morgan & Muir, 2018).
Solution 2.
In the present case study of Eleanor the postoperative bleeding which was caused after hemicolectomy for a poorly differentiated adenocarcinoma of the ascending colon procedures is found to be a rare complication. The problem and its risk was found to be dependent on the hemicolectomy surgery which was performed, the identified co-morbidities of the patient such as hemostatic balance as well as some clotting system. The abnormal heart rate as well as low blood pressure (BP 90/54, HR 106 )as observed in the case within 24 hours might be the indicative factor behind the complication. Low haemoglobin and hematocrit measurements (Haemoglobin (HB) 78g/L, Haematocrit (HCT) 0.36) might also help in determining the loss of blood (Kirchhoff, Clavien & Hahnloser, 2010). Another priority problem recognized is hypertension. The elevated intra-abdominal pressure as observed in the case might cause an adverse effect over several organ systems. The patient has hypertension as depicted in the low sedation score i.e., 1 which might be due to elevations in the pressure of peak airway for the patient. This results in reduced cardiac output which is caused due to additive effects of reduced venous return as well as increasing afterload. The low blood flow is also the factor behind the complication of hypertension as the patient is under hypovolemic shock depicting loss of blood which might result in visceral ischemia (Hammond & Margolin, 2006).
Furthermore, the third problem is hernia which is identified due to the practice of midline laparotomy on the patient. As the contraction in the muscles of the abdominal wall causes retraction in the edges of the wound. Afterwards, due to the avascular nature of the midline incision it might cause impairment in healing of wound, and the the fibres which are present in the linea alba, are present continuously with the wall muscle of abdominal aponeuroses and might cross the midline (Burger, van’t Riet & Jeekel, 2002). CAUTI is one of the common problem associated with the use of indwelling urinary catheter which is linked with high morbidity, mortality. The urinary drainage systems are considered as the place of residence for several multidrug-resistant organisms as well as source of infection in such patient. The prolonged use of urinary catheter might result in the development of CAUTI (Mukhit Kazi, 2015).
Solution 3.
The nursing goal related to blood loss is identified. As a result of the danger of infection transmission related with homologous blood transfusion, new choices in blood treatment – the preservationist and individualized utilization of homologous blood and components; blood substitutes to help oxygen transport (such as changed hemoglobin arrangements), new pharmacologic methodologies for limiting blood loss such as desmopressin, and expanding the body’s capacity to release blood such as recombinant erythropoietin must be considered (Demirci, Zeman, Schmid & Floerchinger, 2017). The nursing goal for hypertension includes antihypertensive medication treatment with vasodilators or adrenergic inhibitors is utilized. Vasodilators as often as possible utilized are hydralazine, sodium nitroprusside, and nitroglycerin. Vasodilators are powerful in BP decrease yet may cause reflex tachycardia when utilized alone (Clement, 2015). The primary nursing goal for hernia includes to evaluates the careful injury site and requests that the patient report pain power level utilizing an approved pain rating scale. Subsequent to giving pain medicine as endorsed with tolerant reaction for adequacy. The nursing goal for CAUTI recognized is to screen unit-explicit CAUTI rates. Screen normal catheter time period (catheter days). Screen SCIP postoperative catheter expulsion on catheterization Day 1 or 2. Pattern unit-explicit IUC use (Mukhit Kazi, 2015).
Solution 4.
Nursing intervention
Rationale
Assessment of the onset of nausea and vomiting, presence of blood, overall physiological assessment if bile, food, as well as odor (Scholz, 2013).
Providing information and knowledge regarding the emesis as well as defining characteristics.
Assessment of the skin turgor, the membrane of the mucous, overall weight, void, as well as changes in behavior.
Providing information and knowledge regarding the hydration status; consisting of the loss of extracellular fluid, reduced level of activity, malaise, loss in weight, low turgor of skin, and concentrated urine.
Assessing the vital signs, which includes apical pulse, heart rate, respiration rate, oxygen saturation, FiO2, sedation level, BP, etc.
Providing regular monitoring of the overall cardiovascular response towards dehydration (such as weakness, thready pulse, low blood pressure, increased heart rate). Increased level of respiratory rate might also contribute towards loss of fluid.
Educating the patient regarding the precautionary measures for the prevention of tissue trauma as well as disruption of the mechanism of normal clotting
Informing about the precautionary measures which tend to reduce the blood loss risk.
Avoiding the rectal suppositories
Such medications might leads to trauma in the lining of mucous in the rectum.
Limiting the strain with bowel movements
Such medications might leads to trauma to the mucous membranes which line the rectum.
Educating the patient as well as the family members regarding any signs and symptoms which needs to be reported (Moore & Murtaugh, 2001).
Early evaluation as well as treatment of blood loss might help to decrease the risk for complications
Antidotes should be given if bleeding is associated with excessive use of anticoagulant.
Protamine sulfate tend to cause a reversal effect of heparin.
Monitoring the skin necrosis,as well as any type of skin color
The patient who are going through the anticoagulant therapy are found to be at high risk of developing emboli.
normal saline nasal sprays should be advised for use
It helps to decrease the drying and cracking of lining of mucous and hence reducing the risk of blood loss.
Teaching the patient regarding the measures which helps in the reduction of constipation such as increased intake of fluid as well as dietary fiber.
Increased level of fluid intake as well as dietary fiber might help in softening the fecal mass to cause easier defecation.
Nurses play a critical activity in the disclosure, checking, and treatment of ailments and in health progression in the system. Subsequently, health training and reinforcing were the essential nursing interventions used to propel health in patients with hypertension inside the ICU, which bases on engaging changes and empowering individuals and systems to improve health. With respect to hypertension, a segment of the health training focuses that nurses should address directions for checking circulatory strain, complexities and holding quick to pharmacological and nonpharmacological medications, for instance, physical exercise, healthy eating standard, smoking and drinking discontinuance, and weight loss. Moreover, the engaged self-care approach bolsters direct changes both in the midst of and after the preparation system. Patients with hypertension anticipate that backing to should hold quick viably to their embraced remedial everyday practice, and nurses have the principle work in giving relevant information to help the fortifying of patients with this affliction (Kirchhoff, Clavien and Hahnloser, 2010).
Nursing interventions inside the Assessment of Needs space recognize and separate social, social and biological practices and are clearly associated with the Planning zone, which expects to make targets subject to the evaluation of necessities and to perceive frameworks reliant on taking in got from hypotheses, confirmation, and practice. It justifies referencing the essentialness of using nursing logical orders in the sorted out organizing of thought, including home thought, to achieve the targets of the supported treatment. The confirmation of using theoretical frameworks as an explanation behind prosperity progression organizing. Such procedures were identified with positive outcomes in the patients’ prosperity conditions. The Health Promotion Model hopes to survey the practices that lead to prosperity progression using three basic parts: particular traits and experiences (prior practices, singular factors); the individual’s assessments and learning of the direct the individual needs to achieve (saw benefits, hindrances, self-practicality, social effects); and charming prosperity headway rehearses (duty to the game plan of movement, solicitations and tendencies). Organization coordination to support opportunity and cooperation were huge nursing interventions inside the Implementation zone, a space that searches for feasible and capable execution, including human and material resource the board, to improve patients’ prosperity. collaborative efforts intends to hoist wellbeing to outfit individuals with health and information on dealing with inconveniences and issues. It in like manner empowers correlative guide, in which individuals manage themselves just as other individuals, similarly as the system and nature (Guedes et al., 2012).
References
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Clement, D. (2015). Control of Hypertension. Hypertension, 65(1), 25-26. doi: 10.1161/hypertensionaha.114.04256
Demirci, C., Zeman, F., Schmid, C., & Floerchinger, B. (2017). Early postoperative blood pressure and blood loss after cardiac surgery: A retrospective analysis. Intensive And Critical Care Nursing, 42, 122-126. doi: 10.1016/j.iccn.2017.02.007
Guedes, N., Moreira, R., Cavalcante, T., Araujo, T., Lopes, M., Ximenes, L., & Vieira, N. (2012). Intervenções de enfermagem relacionadas à promoção da saúde em portadores de hipertensão. Acta Paulista De Enfermagem, 25(1), 151-156. doi: 10.1590/s0103-21002012000100026
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Kirchhoff, P., Clavien, P., & Hahnloser, D. (2010). Complications in colorectal surgery: risk factors and preventive strategies. Patient Safety In Surgery, 4(1), 5. doi: 10.1186/1754-9493-4-5
McNeer, R., & Varon, A. (2013). Pitfalls of Hemodynamic Monitoring in Patients with Trauma. Anesthesiology Clinics, 31(1), 179-194. doi: 10.1016/j.anclin.2012.11.005
Moore, K., & Murtaugh, R. (2001). Pathophysiologic Characteristics Of Hypovolemic Shock. Veterinary Clinics Of North America: Small Animal Practice, 31(6), 1115-1128. doi: 10.1016/s0195-5616(01)50095-9
Mukhit Kazi, M. (2015). Catheter Associated Urinary Tract Infections (CAUTI) and Antibiotic Sensitivity Pattern from Confirmed Cases of CAUTI in a Tertiary Care Hospital: A Prospective Study. Clinical Microbiology: Open Access, 04(02). doi: 10.4172/2327-5073.1000193
Noel-Morgan, J., & Muir, W. (2018). Anesthesia-Associated Relative Hypovolemia: Mechanisms, Monitoring, and Treatment Considerations. Frontiers In Veterinary Science, 5. doi: 10.3389/fvets.2018.00053
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Piras, C. (2017). Hypovolemic Shock. International Physical Medicine & Rehabilitation Journal, 2(3). doi: 10.15406/ipmrj.2017.02.00053
Scholz, J. (2013). Accurate Assessment of Blood Loss Saves Lives!. Journal Of Obstetric, Gynecologic & Neonatal Nursing, 42, S17. doi: 10.1111/1552-6909.12070
Suess, E., & Pinsky, M. (2015). Hemodynamic Monitoring for the Evaluation and Treatment of Shock: What Is the Current State of the Art?. Seminars In Respiratory And Critical Care Medicine, 36(06), 890-898. doi: 10.1055/s-0035-1564874