Clinical Manifestations Of Dehydration, Hypovolemic Shock, Small Bowel Obstruction, And Lab Results

A 52-year-old patient has just arrived in the Emergency Department with complaints of severe abdominal pain, nausea, and vomiting over the last few days. His abdomen is distended. He has poor skin turgor and dry mucous membranes. He has not urinated since yesterday. He has felt dizzy and weak all evening. He thought it might be the flu, but decided to come in because the stomach pains were getting worse. He has signed informed consent for treatment and labs have been drawn.

1. What signs and symptoms did Stan present with that may indicate that he is dehydrated? What nursing care and management is required for the patient presenting with dehydration?

2. One complication of dehydration is hypovolaemic shock. What indicators would you be looking for in a patient with hypovolaemic shock and what would your nursing care be for a patient with this condition?

3. Stan is diagnosed with a Small bowel obstruction (SBO), what is the nursing care and treatment of a person with a small bowel obstruction (SBO)?

4. In evaluating Stan Checketts’ laboratory results, what might his lab results indicate in relation to Stan’s condition? These lab results can be found in the vSim simulation or below

Dehydration and its Clinical Manifestations

1. Dehydration is the condition when the body loses body fluids more than the amount of the water that has been taken, which causes disruption of various metabolic processes of the body due to the imbalanced electrolyte concentration.

Some of the important clinical manifestation of the dehydration includes dry skin, poor skin turgor, nausea, vomiting, decreased urine output and having a dark yellow urine. The case study reveals the fact that Stan had been feeling sleepy and dizzy throughout the day, which is again an important symptom of dehydration (Strachan & Morris, 2017). Dry mucous membrane is also an important sig of the dehydration and may lead to various health problems.

A fluid balance chart should be made for keeping a record of all the food and the drinks supplied to the patients. A multidisciplinary team plays an important role in the record and the documentation of the intake of the fluids and the urine output (Strachan & Morris, 2017). The early warning scores should contain the reviews of the urine output and information about the changes in the vital signs. Following the assessment, a proper management should be made. Fluid replacement is the primary treatment of dehydration. The fluid replacement should be done through mouth, failing this intravenous fluids can be administered. Dehydrated patients who can sit up and drink can be provided with oral rehydration therapy. ORS can be given by nasogastric tube. Stan should be assessed at every one to two hours until the hydration is reached. The ideal intake of the fluid for the older adults is normally calculated as 30 mL/kg/day between 1,500 to 2,000 mL.

Intravenous fluid replacement is a routined pharmacological interventions that can be provided to Stan, as he was vomiting, was having distended abdomen and suffering from hypovolemic shock. Stan can be given ORS solution if he/she is able to take fluids orally (Cortes et al., 2013). The rate of the administration of the fluid can be increased depending upon the condition of the patient. 200ml/kg intravenous fluids can be given in the first 24 hours of the treatment. Once the rehydration is improved the patient can be switched into oral hydration.

2. Hypovolemic shock is an emergency condition in the body that results when 20 Percent of the fluid has been depleted from the body. This can be caused either due to severe dehydration or blood loss. Stan might have suffered from a hypovolemic shock, as most of the symptoms manifested by Stan such as fatigue, insufficient urine retention are the probable signs of a hypovolemic shock. Hypovolemic shock is the most serious and life threatening complications of dehydration. This causes when the low blood volume leads to drop in the blood pressure and a considerable drop in the amount of oxygen in the body. This is mainly caused when there is an equal loss of electrolytes from the body (Kobayashi,Costantini& Coimbra, 2012). Dehydration causes loss of the blood plasma causing a reduction in the blood volume, which can lead to lower venous return and subsequent arterial hypotension. This may again lead to reduced tissue perfusion and myocardial failure due to the enhanced myocardial oxygen demand.

Fluid Replacement Therapy for Dehydration

Some of the indicators of the hypovolemic shock due to dehydration is pale and dry skin, rapid and shallow breathing, little or almost no urine output, weakness or weak pulse and light-headedness and loss of consciousness (Kobayashi, Costantini, & Coimbra, 2012). Internal haemorrhaging can also be caused which can be manifested by the distended abdomen and acute abdominal pain. Signs for external bleeding should be looked for.

Hypovolemic shock, if left untreated can lead to death and should be assessed properly and treated. Nursing management of Hypovolemic shock requires an intravenous fluid replacement therapy and hence should be given for replenishing the fluid loss from the body . Although the intravenous fluids can replenish the fluid volume that was lost but the IV fluids are not able to carry the oxygen like blood. Infusion of the colloids or the crystalloids can be given to compensate the blood clotting factors in the blood (Hasman et al., 2012). Medications may also be prescribed for enhancing the strength of the heart to pump blood. Antibiotic can be applied to prevent septic shock.

3. Small bowel obstruction can be defined as the complete or the partial blockage of the small intestine, that disrupts the normal functioning of the small intestine and block the contents to be passed on to the large intestine (Asiri & Abhinav, 2011).This cause the waste matter and the gases to accumulate above the blockage. This ultimately leads to the disruption of the absorption of the nutrients form the digested food. Small bowel obstruction can be caused by adhesions, hernias, inflammatory diseases (Asiri & Abhinav, 2011).It should be mentioned that nausea, vomiting and distended abdomen are also the clinical features of small bowel obstruction, and hence there is a possibility that Stan might suffer from small bowel obstruction. Furthermore, urine retention in Stan might have been caused due to the small bowel obstruction. Several reports of constipation caused by the urinary retention has been found. Due to the intoxication of the intestinal obstruction, there can be a decrease in the urine ratio and the capacity of the kidney to excrete sodium and hence high sodium content has been found in Stan’s clinical chart.

A fluid replacement therapy is the primary nursing management of the small bowel obstruction diseases. The nursing care management of the small bowel obstruction disease involves proper diagnosis of the condition, followed by a fluid replacement therapy. The patient should be kept in fowler or the semi fowler position for promoting pulmonary ventilation. Patients should limit the oral intake of the fluids as long as the normal electrolytic balance of the body is restored (Loftus et al, 2013). The nasogastric tube is inserted for decompressing the bowel as ordered. Analgesics, broad spectrum antibiotics can be given as ordered. It is essential to monitor the intake and the output of the fluid, the colour of the discharge of the nasogastric tube. The vital signs should be monitored continuously for adverse reactions as well as the desired effects (Loftus et al, 2013).  The nurse should measure the urine output for assessing the renal function, the circulating blood volume and the urine retention of the patient due to the compression of the bladder due to the distended abdomen.

Hypovolemic Shock and its Indicators

4. On venous blood analysis of Stan , the creatinine level in the blood serum has been found to be much higher than the normal value (0.19), whereas the normal range is -0.04-0.07mmol/L. The serum creatinine can increase temporarily if a person is dehydrated or have a low blood volume due to hypovolemia, Whereas, the estimated glomerular filtration rate will decrease. The rise of the creatinine level is due to the poor clearance of the creatinine by the kidneys. High creatinine levels; 0.19 mmol/L, are also predisposing factors to renal diseases. The lab results show a marked increase the chlorine and the sodium ion in the patient. This condition may be termed as hyperchloremia (Suetrong et al., 2016). Hyperchloremia can be observed during acute dehydration. Loss of the body fluids caters to the accumulation of the chloride ions. The chloride levels in the blood alter if the sodium level alters and in the patient chart it can be clearly seen that the sodium level is 150 mmol/L that is higher than the standard value. Hence the sodium levels in the blood have also been found to be much higher than the normal value (Suetrong et al., 2016).

During dehydration, the haemoglobin and the red blood count may show an elevated level, as evident from the reports of Stan showing a haemoglobin count of 200 g/L.  Blood may become concentrated with the loss of water from the intravascular space. They should be rechecked following the hydration process. High count of white blood cells also indicates towards dehydration. All these lab results indicate towards acute dehydration in the concerned patient.

References:

Asiri, A., & Abhinav, V. (2011). A case of small bowel obstruction secondary to intestinal endometriosis. International Journal of Case Reports and Images (IJCRI), 2(8), 12-16.

Cortes, D. O., Santacruz, C., Donadello, K., Nobile, L., &Taccone, F. S. (2014). Colloids for fluid resuscitation: what is their role in patients with shock?.Minerva anestesiologica, 80(8), 963-969.

Kobayashi, L., Costantini, T. W., & Coimbra, R. (2012). Hypovolemic shock resuscitation. Surgical Clinics, 92(6), 1403-1423.

Loftus, T., Moore, F., VanZant, E., Bala, T., Brakenridge, S., Croft, C., ...& Mohr, A. (2015). A protocol for the management of adhesive small bowel obstruction. The journal of trauma and acute care surgery, 78(1), 13.

McNab, S., Duke, T., South, M., Babl, F. E., Lee, K. J., Arnup, S. J., ... & Davidson, A. (2015). 140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): a randomised controlled double-blind trial. The Lancet, 385(9974), 1190-1197.

Perner, A., Haase, N., & Wetterslev, J. (2014). Mortality in patients with hypovolemic shock treated with colloids or crystalloids. JAMA, 311(10), 1067-1067.

Shin, C. I. (2015). Small bowel obstruction. In Radiology Illustrated: Gastrointestinal Tract (pp. 325-349). Springer, Berlin, Heidelberg.

Strachan, S. R., & Morris, L. F. (2017). Management of severe dehydration. Journal of the Intensive Care Society, 18(3), 251–255. https://doi.org/10.1177/1751143717693859

Suetrong, B., Pisitsak, C., Boyd, J. H., Russell, J. A., & Walley, K. R. (2016). Hyperchloremia and moderate increase in serum chloride are associated with acute kidney injury in severe sepsis and septic shock patients. Critical Care, 20(1), 315.