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Mr Simpson is hypotensive, tachycardic and tachypnoeic most likely due to dehydration. With reference specifically to Mr Simpson’s history and presentation, explain the physiological causes of hypotension, tachycardia and tachypnoea. Your answer does not require potential diagnoses; but rather a focus on the causes and emergence of these findings specifically drawing on determinants of cardiac output and compensatory mechanisms.

Mr Simpson, aged 68 years, was playing golf with his friends when he reported feeling dizzy. He had been playing for several hours on a 37 o

It is the fourth consecutive day with temperatures over 35o

His skin is flushed, he is agitated and drowsy. Mr Simpson has a pasthistory of an anterior myocardial infarction, hypertension, and a recent echocardiogram confirmeda left ventricular ejection fraction of 26%. His usual medications are: metoprolol 25 mg bd, ramipril5mg mane, atorvastatin 40 mg nocte, and aspirin 100 mg mane. It is unclear whether Mr Simpson is fully compliant with his medication regime.

You are the critical care nursing student responsible for this gentleman’s care. Your initial assessment findings are:

  • respiratory rate: 28 breaths per minute
  • blood pressure: 89/44 mmHg
  • pulse: 107 bpm (regular)
  • SpO2: 93% on room air
  • temperature: 37.4 degrees Celsius
  • GCS score: 15
  • reports pain score of 0

Mr Simpson requires intravenous fluids to restore his circulating blood volume. A central venous catheter (CVC) has been inserted. Hartmann’s solution, 0.9% Normal saline, 5% Dextrose, or Packed Cells are the fluid replacement options discussed. Based on research evidence, explain why or why not each of these options should be infused.

Select eight specific nursing/collaborative assessments the registered nurse should perform and monitor toevaluate the reestablishment of normal fluid and electrolyte homeostasis for this patient. For each assessment, provide the physiological rationale for performing/monitoring each assessment/parameter.

Provide an overall interpretation of Mr Simpson’s arterial blood gas results and provide a physiological explanation for any deviations noted for each parameter.

  • pH 7.30
  • PaCO2 30 mmHg
  • PaO2 83 mmHg
  • SaO2 94%
  • HCO3 20 mmol/L
  • Lactate 3.2 mmol/L

Suggest four possible reasons for this rhythm in this patient. Provide a physiological rationale for each. On assessment of Mr Simpson’s heart rate, an irregular rhythm is noted.

Mr Simpson undergoes a portable chest X-ray. Describe and rationalise four (4) factors or issues that should be evaluated by the nurse to assess the quality of a chest x-ray prior to performing an analysis of a chest xray.

“The notion that adverse events are sudden, unexpected and occur without warning has now been challenged and there is evidence that, for the majority of patients who suffer an in-hospital adverse event, the event is preceded by a period of physiological abnormality, whereby the patient exhibits clearly abnormal physiological signs.” (Considine & Botti, 2004, p. 23).

Medical emergency team (MET) activations are made for hypotension. Abnormal arterial systolic blood pressure measurements are strongly predictive of adverse hospital outcomes such as unexpected death, cardiac arrest, unplanned ICU admission and medical emergency team activations.

With reference to literature, critically discuss the importance of accurate blood pressure measurement; recognition, documentation and escalation of care for hypotension; and the sensitivity of hypotension as a predictor of critical illness. Primary sources from 1990 onwards are acceptable for this question. Full referencing is mandatory for this question.

Physiological causes of hypotension, tachycardia, and tachypnea

One of the main reasons of hypotension is the dehydration. Mr. Simpson loss more amount of water than the taken water therefore, it suffers from the dehydration. The hypotension can lead various types of health issues like heart attack, bradycardia, heart valve disease and the heart failure (Ricci, Caterina & Fedorowski, 2015). Heat stroke can be another reason of hypotension. The cardiac output of Mr. Simpson decreased with the heart rate.  Therefore, he has the risk of heart failure. Absence of perspiration and change in urine color indicates that a person is suffering from hypotension. Excess heat may cause of drowsiness and agitation that results the hypotension. Autonomic nervous system regulates the blood pressure continuously by the nerves, receptors and hormones. The alpha and beta-blockers plays a vital role in the hypotension.  

Tachycardia refers to the rapid heart rate that is abnormality in heart rate. When the normal electrical impulses get disrupts, a serious problem, named tachycardia happens. However, the electric impulses control the pumping action of heart. Mr. Simpson is suffering from tachycardia. Tachycardia happens due to damage of heart tissues from the heart disease. Excess exercise also may cause tachycardia. Hall (2015) mention that high and low blood pressure, smoking, intake of excess alcohol can cause of tachycardia. In case of Mr. Simpson, tachycardia may cause the damage of the heart tissues completely.  The risk factors that increases the chance of tachycardia are heart disease, sleep apnea, smoking,  overactive or underactive thyroid, high  or low blood pressure, use  of the recreational drugs and anemia.                

According to Aitken, Marshall and Chaboyer (2016), tachypnea is a medical term that indicates the rapid and deep breathing. The normal breathing rate of adult human being is in between 12 to 20 per minute. When the rate goes above 20 per minute, the symptoms of tachypnea are seen. Tachypnea can have either physiological or the pathological causes. Physiological causes may include the excess exercise in pregnancy and old age.  The cause of tachypnea of Mr. Simpson is blockage of the breathing system. Carbon monoxide poisoning may result of tachypnea, in which the delivery of oxygen is hampered. 

In case of Mr. Simpson, he has the visual physiological symptoms of hypotension, tachycardia and tachypnea.

Based on the research evidence, it is found that Hartmann’s solution, 5% Dextrose, Packed cells and 0.9% Normal saline are not used together. The main reason of this is the similarity of the functions. 0.9% Normal saline is used to treat the dehydration theretofore the low blood pressure. Hartmann’s solution helps to electrolyte the patients who have low blood pressure (Davis & Fisicaro, 2016). Five% dextrose works as the intravenous sugar solution that helps in the treatment of low blood sugar. Packed cells help to increase the amount of hemoglobin to cure the lung injury. 

Nursing assessment for evaluating the reestablishment of normal fluid and the electrolyte balance:

  1. Monitor vital signs and symptoms:

Tachycardia is present with the hypotension and fluid deficit. Central venous pressure measurement is useful to determine the degree of fluid insufficiency and response to the replacement therapy.

  1. Monitor urinary output:

Evaluation of fluid replacement options

Fluid replacement is necessary based on correction of recent deficit and the ongoing losses. Renal hypovolemia or polyuria may present and need fluid replacement.  

  1. Evaluation of the ability of the patient to swallow:

Impaired swallow reflexes, oral discomfort, nausea and unconsciousness that may affect the ability of patient to replace the fluids orally (Lewis et al., 2016).

  1. Give skin and mouth care to the patient

Mucous membrane and skin may dry with the reduced elasticity due to vasoconstriction and intracellular water decreasing.  

  1. Monitor the evaluation of the restlessness, BP, increased anxiety:

Cardiopulmonary system may comprise the fluid deficit especially if the colloids are used in fluid replacement.

  1. Monitor laboratory studies

Depending on the fluid loss, metabolic imbalance can be need correction. For example, use of the glucose solution in the service user with the underlying glucose intolerance. This can result in the serum glucose elevation.

  1. 45% NACL lacted Ringer’s solution

Crystalloids give proper circulatory development and can increase the renal clearance.

  1. Administer sodium bicarbonate  

Correct the fluid balance with the acidosis by the sodium bicarbonate.

At first the pH of normal blood is determined that is 7.30. From this result, it is seen that the blood is acidic.

Normal PaCo2 level of human is 35-45 mmHg (Naisbitt, Buckley & Kishen, 2016). However, the PaCo2 level of the patient is 30 mmHg, which is lower than the normal value. It is alkalotic.

The normal value of HCO3 is 22-26 mmol/L. However, the HCO3 level of the patient is 20 mmol/L, which is acidotic.

The matching of Co2 or HCO3 with pH shows the acid base disorder in a patient. The patient may suffer from the respiratory problems.

In case of the patient, the PaCo2 is going to the opposite direction of the pH and HCO3. Therefore, the patient can be affected by the primary acid base disorder that is respiratory acidosis.  

The pO2 of the patient is 83 mmHg, whereas the normal value is 80-100 mmHg. Therefore, form the result it can said that the pO2 is not saturating.

Electrical impulses come from different parts of heart rather than sinus node:

It can change the vascular function and neurohumoral status.

Electrical impulses come from sinus node and go to lower chambers of heart:

It raises the pressure on the ventricle therefore; the oxygen supply is hampered (Lewis et al., 2015).

Blocking of sinus node:

It raises the chance of heart failure.

Changes in heart muscle:

It influences the chance of systolic dysfunction.

Before the x ray, the jewelry of the patient should be removed. Moreover, the patient should change his clothing also and wear the exam gown for the x ray. Both the jewelry and clothing can provide vague image of x ray.

Another factor that can affect the clear image of the x ray is the wrong position of body part. The part of body needs to be in between the film plate and x ray beam.

The patient needs to hold the breathing during taking the picture of x ray of chest that will provide the clear image of x ray of chest.

The nurse should ask the patient to lie straight and motionless. He should not move during taking the image of chest that can make the image blurred (Harring Deal & Kuo, 2014).

Specific nursing/collaborative assessments

Accurate blood pressure measurement:

To measure the blood pressure accurately, it is necessary to choose right equipments like quality stethoscope, blood pressure cuff, aneroid and sphygmonometer. Accurate blood pressure measurement shows crucial signs with the weight and temperature.  The patient needs to sit upright and the position of the upper arm should be leveled with heart and feet should be flat on floor. The size of the blood pressure cuff should be appropriate. Wrong measurement of blood pressure can give abnormal result (Cowley, Owen & Bion, 2013). Therefore, determination of hypotension or hypertension cannot be determined properly. Hypertension can lead to heart attack, renal failure and stroke. Hypotension can lead the chance of nausea, faint and coma. If the measurement of blood pressure is not accurate then it can raise the chance of mentioned health issues.

Recognition, documentation and escalation of hypotension care:

Recognition of hypotension care plays important role in nursing. In case of Mr. Simpson, the hypotension is detected by the observing the signs and symptoms. Some signs and symptoms of hypotension are dizziness, fainting, blurred vision, shallow breathing, and nausea and fatigue (Lewis et al., 2015). The blood pressure of Mr. Simpson was measured by the sphygmonometer.

The documentation of hypotension is very important. The documentation includes the measurement of systolic and diastolic pressure, symptoms of the patients. The medication also should be documented for the patient. The nurse needs to aware the patient about the symptoms and causes of hypotension. The patient needs to intake proper amount of fluids including water, drinks with potassium and sodium. The patient needs to follow the comments of the nurse. He should not sit crossing the leg and should stand up slowly. The nurse should provide high carbohydrate diet to resist the hypotension and raise the blood pressure. The nurse should provide the medication on time to the patient and should provide intravenous injection if necessary.

Sensitivity of hypotension as the predictor of critical illness:

Critical illness related corticosteroid insufficient refers to the adrenal insufficiency in the serious ill patient. Corticosteroid helps the tissues of heart to response against the hypotension (Katz, 2016). For the intensive care service users, the adrenal deficiency constitutes the negative effect. The pituitary gland and hypothalamus controls the adrenal secretion that changes at the time of critical illness. The high and low levels of the cortisol are linked with the poor outcome of intensive care service users. This high level can show several stress in the patient. In case of hypotension, the CIRCI may be suspected in the service users despite of the resuscitation with the intravenous fluid and the vassopressor drugs. Critical illness can occur at the time of hospitalization in 5% of development and the validation cohorts.


Aitken, L., Marshall, A., & Chaboyer, W. (2016). ACCCN's Critical Care Nursing. Elsevier Health Sciences.

Considine, J., Trotter, C., & Currey, J. (2016). Nurses' documentation of physiological observations in three acute care settings. Journal of clinical nursing, 25(1-2), 134-143.

Cowley, N. J., Owen, A., & Bion, J. F. (2013). Interpreting arterial blood gas results. BMJ, 346, f16.

Davis, E., & Fisicaro, M. (2016). Tachypnea and hypopnea. Post-Anesthesia Care: Symptoms, Diagnosis, and Management, 80.

Hall, J. E. (2015). Guyton and Hall textbook of medical physiology. Elsevier Health Sciences.

Harring, T. R., Deal, N. S., & Kuo, D. C. (2014). Disorders of sodium and water balance. Emergency medicine clinics of North America, 32(2), 379-401.

Katz, A. M. (2016). Contractile proteins of the heart. Physiological Reviews, 50(1), 63-158.

Lewis, S. L., Maltas, J., Dirksen, S. R., & Bucher, L. (2015). Study guide for medical-surgical nursing: Assessment and management of clinical problems. Elsevier Health Sciences.

Lewis, S. L., Sandstrom, S. A., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Study Guide for Medical-surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.

Naisbitt, C., Buckley, H., & Kishen, R. (2016). Crystalloids, colloids, blood products, and blood substitutes. Anaesthesia & Intensive Care Medicine, 17(6), 308-314.

Pinnington, S., Ingleby, S., Hanumapura, P., & Waring, D. (2016). Assessing and documenting fluid balance. Nursing Standard, 31(15), 46-54.

Ricci, F., De Caterina, R., & Fedorowski, A. (2015). Orthostatic hypotension: epidemiology, prognosis, and treatment. Journal of the American College of Cardiology, 66(7), 848-860.

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