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Consequences of hypovolemia

Discuss about the Importance in Darren’s Case Study.

Fluid management is a crucial aspect of the complete surgical therapy. It is important to administer proper amount of fluid in people who have undergone major surgeries like emergency laparotomies, bowel resections and hepatectomy procedures (Dellinger et al., 2013). This is because due to surgery, body fluid composition changes and can result in impaired healing of wound, homeostasis and hypovolemia and so on. Hence, it is important for the physicians to determine the choice of strategy in intra and post-operative fluid management as it is crucial for patient improvement (Lawindy et al., 2012). In this case study of Darren Roberts in the first 4 hours of his discharge from PARU and return to the ward following his surgery, it has been observed that he has developed pale, cold and clammy skin in postoperative system. Further, as the physicians performed more physical assessment, it was observed that Darren has low blood pressure with reading 90/60 and the respiratory rate was lowered with reading > 20Rpm. Besides these, when the physicians tested the urine output, it showed decreased output results. Hence, all these test result indicated that Darren had the potential risk for hypovolemia, a condition in which, the patient decreases the amount of blood and fluid in the body, due to inter-operative trauma and situation. Peri-operative safeguarding of sufficient intravascular volume status is significant in achieving optimal outcomes after surgery. However, there are arguments regarding both composition and volume of intra-operative fluid therapy (Geerts et al., 2012). This section will review derangements and monitoring of intravascular volume status of Darren in the healthcare setting, as well as strategies for choosing appropriate composition, quantity, and timing of intra-operative fluid management.


There are several consequences of hypovolemia due to which this is an severe risk condition for Darren. These consequences have been mentioned in the following sections. This decrease in the blood volume in the body causes lowered vein returns and in much more severe condition, it leads to arterial hypotension (Agaba, Rohrscheib & Tzamaloukas, 2012). Due to this condition, compensatory systemic release of catecholamine becomes activated that eventually promotes the peripheral vasoconstriction, tachycardia and increased cardiac related contractility. In this condition, the systemic blood pressure remains stable however due to increased hypovolemia and developed tachycardia and increased oxygen demand (myocardia), which with less tissue perfusion, may result in myocardial failure. Further, anaerobic metabolism occurs in response to the reduced perfusion that may produce acidosis and in combination with myocardial dysfunction, contribute to multi-organ failure. In such situation the patient, also can loss up to 15% of the blood volume of the entire body decreases, hence the chances of  affected arterial pressure or reduced cardiac output increases (Aman, Groeneveld & van Nieuw Amerongen, 2012). However, more than that can affect cardiac output due to decreased preload, and oxygen delivery leading to the tissues falls and decreases the arterial pressure too. This condition with hypotension affects different organ function especially in splanchnic organs as in this organ α-adrenergic activity is relatively high and this makes the splanchnic region is highly vulnerable in patients with hypovolemia shock and hypotension (Nelson et al., 2012). Further, the mucosal integrity may also be compromised and due to this impaired gut barrier, translocation of bacteria and end toxins occur, creating a complete provocative reaction because of shock wave. Moreover, related to adverse hypovolemia, due for occurrence to trauma, these pathophysiology related procedures may eventually lead to the expansion of sepsis (Geerts et al., 2012). Therefore, due to these reasons, it is a risky situation for Darren.

Patient-centered smart goal for Mr. Darren

The patient centered smart goal for Mr. Darren will be such as-

Mr. Darren will maintain appropriate cardiac output, evidenced by stabilization of systolic blood pressure and heart rate, maintenance of consciousness level and adequate urinary output and the period will be 4 weeks.

As due to preoperative and intra-operative shocks, Darren has the risk to develop Hypovolemia, the interventions should target four aspects such as reduced cardiac output, lacking Fluid Capacity, in affective tissue perfusion, and anxiety. The interventions their rationale and their desired outcome have been presented below.

The first nursing intervention was directed towards decreased cardiac output and the desired outcome will be such that Darren will maintain sufficient cardiac output and the systolic blood pressure will be 20 mm Hg of baseline Further strong peripheral pulse will be observed with heart rate 60 to 100 beats per minute with regular rhythm. Further, his skin will be warm and dry with normal consciousness (Rihal et al., 2015). Firstly, the clients heart rate and blood pressure with peripheral pulses further the direct intra-arterial monitoring order will be used. The rationale to it will be usage of Sinus tachycardia and increased arterial blood pressure related observation in the early stages to maintain an adequate cardiac output. Further, Vasoconstriction can also leads to decreased cardiac output. Hence, it will be assessed. Further, to maintain the blood level, and adequate cardiac output, blood plasma transfusion, red blood cell transfusion, platelet transfusion and intravenous crystalloids will be used for Darren. This is also important as with shock progression, aerobic metabolism stops and lactic acidosis occurs, resulting in the increased level of carbon dioxide and decreasing pH (Rihal et al., 2015).


The second intervention will be directed for deficient fluid volume and the desired outcome will be Darren’s normovolemic condition that will be assessed by Heart rate 60 to 100 beats per minute. The systolic Blood Pressure greater than or equal to 90 mm Hg, orthostatic will be absent and the urinary output will be greater than 30ml/hr with normal skin turgor. Firstly, the  possible sources of fluid loss will be monitored in Darren as there are different sources can be possible for fluid loss such as diarrhea, vomiting, wound drainage, severe blood loss, profuse diaphoresis, high fever, polyuria, burns, and trauma (Hampton et al., 2013). Further, for his post surgical source of fluid loss  his skin area will be marked, dressing will be weighed to determine fluid loss, chest tube drainage will be monitored. It is an important intervention as an expanding hematoma or swelling or increased drainage helps to identify bleeding or coagulopathy. Depending on the Darren’s ability, a spun hematocrit will be obtained, and will be reevaluating every 30 minutes to 4 hours. Hampton et al., (2013) determines that because of dilution, hematocrit decreased as fluids are administered. Hence using this i9ndicator of hematocrit decrease, estimated blood loss can be assessed in Darren.

Nursing interventions to stabilize Mr. Darren's condition

The third intervention will be ineffective tissue perfusion and the desired outcome will be such that Darren will be able to conserves extreme tissue perfusion in important organs, as evidenced by warm and dry skin, present and strong peripheral pulses, vitals within patient’s normal range, absence edema, and absence of chest pain (Corstiaan et al., 2014). Firstly, the patient will be assessed for decreased tissue perfusion. This is important as specific groups of signs, symptoms occur with differing causes, and assessment of these will provide a baseline for future comparison. Further different aspects such as pallor, cyanosis, and mottling, cool or clammy skin will be observed in Darren and quality of every pulse will be assessed. If peripheral pulses are found non existing, then it essential be conveyed or accomplished directly.  Furthermore, systemic vasoconstriction causing from decreased cardiac output will be established by weakened skin perfusion and loss of pulsations and this is because continuous assessment will be carried out. Besides these, the blood pressure readings for orthostatic changes will be recorded, as steady Blood Pressure is needed to possess adequate tissue perfusion. There are several factors such as medication effects, altered autonomic control, reduced fluid volume, and vasodilatation can be hampering the optimal blood pressure hence it will be observed (Corstiaan et al., 2014).

For the decreased cardiac output, evaluation will be based on the applied interventions. hemodynamic stability will be assessed with blood pressure, cardiac output, renal perfusion/urinary output, peripheral pulses related assessments. Further blood report will be reviewed so that components such as complete blood cell—CBC—count, electrolytes, ABGs, blood urea nitrogen/creatinine—BUN/Cr—cardiac enzymes, and cultures, such as blood/ wound/secretions can be clearly understood. Different diagnostic studies to understand the heart condition such as pharmacological stress related testing, ECG, and scans, echocardiogram, heart catheterization will be done. Finally the Monitor cardiac rhythm will be continuously noted so that efficiency of medicines and/or devices (e.g., implanted pacemaker/ defibrillator) can be understood while evaluation (Rihal et al., 2015).

The fluid volume will be evaluated using blood pressure. The concept is such that greater than 10 mm Hg drop in blood pressure indicates that the blood volume circulating in the body is reduced by 20%, whereas more than 20 to 30 mm Hg drop determines that the blood volume within the body is reduced by 40%. Further, orthostatic hypotension triggered by volume reduction is related to a compensatory rise in HR (additional than 20 beats/min) (Hampton et al., 2013). Further record of administered IV fluid will be assessed so that the fluid intake can be understood. This is important as adequate fluid consumption upholds suitable filling pressures and enhances cardiac output required for tissue perfusion (Corstiaan et al., 2014).

Evaluation of decreased cardiac output

References

Agaba, E. I., Rohrscheib, M., & Tzamaloukas, A. H. (2012). The renal concentrating mechanism and the clinical consequences of its loss. Nigerian medical journal: journal of the Nigeria Medical Association, Vol. 53, issue. 3,pp. 109. doi:  10.4103/0300-1652.104376

Aman, J., Groeneveld, A. J., & van Nieuw Amerongen, G. P. (2012). Predictors of pulmonary edema formation during fluid loading in the critically ill with presumed hypovolemia. Critical care medicine, vol. 40, issue. 3, pp. 793-799. doi: 10.1097/CCM.0b013e318236f2df

Corstiaan, A., Lagrand, W. K., van der Ent, M., Nieman, K., Struijs, A., Jewbali, L. S., ... & Simoons, M. L. (2014). Conventional hemodynamic resuscitation may fail to optimize tissue perfusion: an observational study on the effects of dobutamine, enoximone, and norepinephrine in patients with acute myocardial infarction complicated by cardiogenic shock. PLoS One, Vol. 9, issue. 8, e103978. DOI: https://doi.org/10.1371/journal.pone.0103978

Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S. M., ... & Osborn, T. M. (2013). Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive care medicine, vol. 39, issue 2, pp. 165-228. DOI: DOI https://doi.org/10.1007/s00134-012-2769-8

Geerts, B. F., van den Bergh, L., Stijnen, T., Aarts, L. P., & Jansen, J. R. (2012). Comprehensive review: is it better to use the Trendelenburg position or passive leg raising for the initial treatment of hypovolemia?. Journal of clinical anesthesia, vol. 24, issue 8, pp. 668-674. DOI: https://doi.org/10.1016/j.jclinane.2012.06.003

Hampton, D. A., Fabricant, L. J., Differding, J., Diggs, B., Underwood, S., De La Cruz, D., ... & Alarcon, L. H. (2013). Pre-hospital intravenous fluid is associated with increased survival in trauma patients. The journal of trauma and acute care surgery, vol. 75, issue 1, pp. S9. doi:  10.1097/TA.0b013e318290cd52

Lawindy, S. M., Kurian, T., Kim, T., Mangar, D., Armstrong, P. A., Alsina, A. E., ... & Spiess, P. E. (2012). Important surgical considerations in the management of renal cell carcinoma (RCC) with inferior vena cava (IVC) tumour thrombus. BJU international, vol. 110, issue 7, pp. 926-939. DOI: https://doi.org/10.1111/j.1464-410X.2012.11174.x

Nelson, J., Billeter, A. T., Seifert, B., Neuhaus, V., Trentz, O., Hofer, C. K., & Turina, M. (2012). Obese trauma patients are at increased risk of early hypovolemic shock: a retrospective cohort analysis of 1,084 severely injured patients. Critical Care, vol. 16,issue. 3, pp. R77. DOI: https://doi.org/10.1186/cc11334

Rihal, C. S., Naidu, S. S., Givertz, M. M., Szeto, W. Y., Burke, J. A., Kapur, N. K., ... & Tu, T. (2015). 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care (Endorsed by the American Heart Association, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology–Association Canadienne de Cardiologie d'intervention)∗. Journal of cardiac failure, vol. 21, issue 6, pp. 499-518. DOI: https://doi.org/10.1016/j.cardfail.2015.03.002

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