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Pathophysiology of post-operative hypovolemia

Discuss about the Nursing Practice in Context for Evidence-Based Nursing.

The post-operative hypovolemia indicates a decrease or reduction in the blood volume due to the absence of sufficient blood plasma also known as volume contraction occurring due to blood loss or sodium or intravascular water loss from the body (Yoder-Wise, 2014, p.90). According to Geerts et al. (2012,p. 670) studies, any condition like vomiting, diarrhoea, injury, large burns, and insufficient fluid intake can contribute to the hypovolemia condition. Basically, there are four stages of hypovolemia out of which the fourth stage is considered to be most severe state of hypovolemia shock. In the present case study, Mr. Jensen is in 3rd stage of hypovolemia where his systolic BP

Loya et al. (2012, p.616) indicated that the state of hypovolemic shock is a stressful stage where the body does not persist enough blood to fulfil its requirements leading to decreased blood pressure or hypotension development in the body. As the heart is not able to get sufficient pumping blood it leads to lowering blood pressure. Kobayashi, Costantini & Coimbra (2012, p. 1410) studied that initial stages of hypovolemic there is a loss of skin elasticity, dryness and lower urine output. To overcome this blood loss, human body tries to compensate by accelerating heart rate, heart contractions and shrinking periphery blood vessels. But, in the state of continuous blood loss, the compensation ability of body gets reduced that results in hypotension development. Mr. Jensen is observed of having this severe state of hypovolemic shock where his pre-operative condition of hypertension has now become hypotension due to huge fall in his blood pressure from BP- 155/100 to BP-104/55.

Geerts et al. (2012, p. 672) studied that hypotension is a state of decreased blood pressure rather than low blood pressure that is identified by a comparing the current BP and baseline BP of the patient. Therefore, Mr. Jensen is in hypotension state where his current BP is very low when compared to his baseline blood pressure. This hypotension is the outcome of hypovolemic shock condition that is produced by the different bodily system to control haemorrhage.

According to Weingarten et al. (2012, p.45) there is activation of the coagulation cascade and shrinking of blood vessels by the hematologic system to compensate blood losses in the body. The thromboxane A2 gets activated creating immature clot in the bleeding source that takes 24 hours for maturation. Therefore, the body remains in a state of hypovolemic shock for the minimum period of 24 hours. Further, Kobayashi, Costantini & Coimbra (2012, p. 1416) studied indicated that cardiovascular system of the body shows acceleration in myocardial contraction, heart rate and peripheral blood vessels contraction in response to hypovolemia. This leads to lowering of blood pressure in the body. The renal system of the body reacts by acceleration in renin secretion, which leads to the development of Angiotensin II. This Angiotensin II helps by reversing the stressful haemorrhagic situation by activating aldosterone secretion that improves sodium reabsorption in the body.

Identifying priority problems of Mr. Jensen as per ABCDE approach and their justification

According toHolte (2010, p. 4156),pathophysiology of postoperative hypovolemia is highly contributed by the neuroendocrine system that leads to lower urine output in the body. The activation of antidiuretic hormone (ADH) is initiated by the neuroendocrine system as a response of hypotension. This ADH favours an increase in reabsorption of salt and water in the loop of Henle, collecting ducts and distal tubule in the kidney. Therefore, a decreased urine output is observed as a symptom of hypovolemia. In the case of Mr. Jensen decreased urinary output identified as post-operative condition contributes to hypovolemic shock. His urinary output of>1ml/kg/hr and dilute indicates a much low level of urine output from his body.

Further, there are many indications in assessment data of Mr. Jensen that must have contributed to the pathophysiology of hypervolemia stressful condition where he had a cold body indication as the initial symptom of stress. The heart rate of Mr. Jensen was recorded as 107BPM that is little higher than normal heart rate indicating cardiovascular activities of hypervolemia state working to manage decrease in the blood pressure. He was under Hartmann’s Solution intake at 125mIs/hr that is a replacement for lost mineral salts and body fluid indicates a loss of body fluid in his body. He was also under the state of hypoxemia having FiO2 
6 ltires supply to the body. Geerts et al. (2012, p. 669) indicated that hypoxemia is also a part of hypervolemia pathophysiology where a low level of blood plasma leads to low oxygen absorption it the blood creating respiratory disorder.

The organs like brain, heart kidneys and liver of body win to overcome the traumatic condition of hypovolemic but organs like skin, GI tract and skeletal muscle fails to do so. The physiology of body response involves increased respiration, cardiac output and retention of sodium. But, the body is not able to compensate hypotension and tachycardia situation occurring in this condition. There is an increase in vasopressin, epinephrine and angiotensin by the body to overcome this state with baroreceptor-mediated vasoconstriction (Polit & Beck, 2013, p.101). This results in lower urine output, minimized pulse rate, tachypnea and tachycardia (Schlag & Redl, 2012, p. 90).

The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) exposure approach is the most reliable and acceptable clinical approach of immediate patient assessment to allow immediate essential interventions and treatment. ABCDE approach is used in case of all clinical emergencies and injuries where specific techniques are applied to gather data about the critical problems confronted by the patient (Morandi, Brummel & Ely, 2011, p. 46). In this study, ABCDE approach is used to access the priority problem of Mr. Jensen that requires proper treatment and intervention.

Airway evaluation

This is the very first step of ABCDE assessment approach where the airway obstruction of the patient is identified using “see-saw” respiration technique. This is done to access any kind of obstacle in the airway that can harm the normal breathing and speech of the patient (DiCenso, Guyatt & Ciliska, 2014, p. 145).

In the case of Mr. Jensen, he is observed to be having a clear airway obstruction because he is already on FiO2 with normal respiration rate 24BPM indicated in his assessment data.

Breathing evaluation: This assessment involves identifying the respiratory rate, movements of chest walls, pulse oximetry, chest beating and auscultation of lungs. The main aim of this assessment is to determine the breathing depth, respiratory patterns and chest deformities occurring due to illness or injury. This process involves recording the respiratory rate and SpO2 rate (Wilson & Giddens, 2014, p.120).

In the case of Mr. Jensen, there is no priority issue identified for his breathing as he is having a normal respiratory rate and SpO2 rate as per his assessment data.

Circulation evaluation: This assessment step involves identifying the issues in the circulatory system of the body that are identified by abnormal symptoms in skin, pulse rate, blood pressure, ECG monitoring, and capillary refill time (CRT). In the case of injury, the external condition is examined to determine the severity of haemorrhage (DiCenso, Guyatt & Ciliska, 2014, p. 145).

In the case of Mr. Jensen, the circulation evaluation indicates a major problem of hypotension indicated by low diastolic blood pressure count that is 55. He is also having a fluid loss problem, which is compensated with Harman’s Solution running at 125mls/hr. Another priority issue is to manage the low urine output of Mr. Jensen that is only >1ml/kg/hr, as well as urine, is very dilute indicating a major issue. He is also having a slightly higher heart rate, which is 107 BPM that is higher from normal heart rate that should be within 60 to 100 beats per minute. Further, his wound condition is critical having notable swelling and appearance of sereous ooze with the injured leg being cool when touched. These assessment conditions confirm the presence of hypovolemia as another priority concern in the patient.

Disability evaluation: The disability evaluation involves determining the pain responsiveness, alert, and voice responsiveness along with accessing the blood glucose level, limb mobility and pupillary reflexes as per the conscious state of the patient (Wilson & Giddens, 2014, p.122).

In the case of Mr. Jensen, he is having a priority issue of high pain score that is 7 out of 10 indicating a requirement of pain management. He is also identified with a very high blood glucose level of 17mmols/ltr. 2mIs/hr unit of insulin and dextrose infusion manages his high blood glucose.

Exposure: This assessment is used to identify the exposed skin condition and temperature of the patient body (Wilson & Giddens, 2014, p.125). In the case of Mr. Jensen, he is having a normal body temperature.

Describing nursing goal for each identified priority problem in case study

The below-provided table involves the nursing goal for the care of each identified health problem in the case of Mr. Jensen along with its explanation.

Health problem

Nursing goal

Explanation

Hypovolemia

To maintain and monitor the normal body fluid balance

This goal will help to overcome the state of hypovolemic shock in the patient. Further, monitoring will help to manage the fluid balance to avoid Hypovolemia in future (McGregor et al. 2012, p. 510).

Hypotension

Physical activities and movements support an increase to blood circulation

The minor physical movement will help in increasing body heat and blood circulation (Chan & Perry, 2012, p. 2255).

Low urine output

Maintain 24-hour balance of input and output body fluid

This goal will help to overcome the deficient fluid volume in the body of patient (Chianca et al. 2012, p. 860).

High pain score

Pain controlled and complication prevented

This goal will focus to apply intervention for minimizing the pain score of 7 (Merriman, Stayt & Ricketts, 2014, p. 120).

High blood sugar level

Provided education about self-care management technique (DSME)

The goal is let patient understand the seven elements of self-care for managing diabetes mellitus type -2 (Fairman et al. 2011, p. 194)

High heart rate

Deficient knowledge addressed and implemented for patient

This goal will address the knowledge defects regarding self-care and treatment regarding heart problems (Stevenson et al. 2014, p. 256)

Fracture swelling

Control over critical condition

This nursing goal will involve care techniques to minimize the swelling issue (Cwik, 2012, p. 441)

Serous exudate in fracture site

Successful monitor and documentation of exudate condition

This goal will work to detect the complications such as infection in the wound (Chan & Perry, 2012, p. 2254).

Pain controlled and complication prevented

Nursing intervention

Rationale

Provide immobilization of injured body part or organ with the help of support, bed rest, splint, cast and traction

This intervention was practice in the study of Stevenson et al. (2014, p. 283) where immobilization was maintained for pain relief that also helped in preventing complications like bone displacement and other injuries. Borchers & Gershwin (2014, p. 245) indicated that it is better to immobilize the painful part or organ in the state of fracture to avoid extension of injury. This intervention works to minimise the high pain score of the patient.

Avoid or replace the Lenin bed sheets, plastic covers and pillows under limbs in the chuck.

This intervention will minimize the discomfort that can occur due to the fiction of such materials used in beddings. Kobayashi, Costantini & Coimbra (2012, p. 1410) indicated that clothes like Lenin’s and chiffon can lead to heat production in the body as well as pressurization on injuries.

Periodic and regular ROM exercises for other regions of the body except injured parts.

This intervention provides strength and functionality to other body parts or muscles that facilitate the treatment of injured parts or muscles. Borchers & Gershwin (2014, p. 253) indicated that Range of Motion (ROM) exercises are specifically meant for specific body parts. Therefore, they can best address to provide mobility under fracture conditions for other parts of the body. Kobayashi, Costantini & Coimbra (2012, p. 1419) studied a survey in hospital where patient practising ROM exercises dwell early recovery in comparison to non-participating patients.

Apply stress managing and comfort providing techniques (massage, relaxation, deep breathing, talking, backrub)

Lave et al. (2014, p. 9) indicated that nursing stress management in painful condition gets a control over pressure, anxiety promotes sensory stimulation, and minimises the traumatic condition. These nursing stress managing and comfort providing techniques persist invisible pain control processes.

Periodic evaluation and documentation if discomfort and pain using similar pain scale tool (0-10 scale). Observe and document the non-verbal vital signs, movements, behaviour and emotions of pain.

A continuous pain evaluation and monitoring helps to determine the effectiveness created by nursing interventions in the present condition of pain. Further, documenting pain-monitoring outcomes is a nursing duty that can further help the physician in developing the treatment protocol. Lave et al. (2014, p. 7) indicated that regular pain evaluation in between score of 0-10 provides a numerical report of patient pain that can be considered as a prove of successful intervention. However, Stevenson et al. (2014, p. 282) indicated that there are feeling like anxiety, stress etc. can lead to expressionless pain. Therefore, dependency on the pain scale is not completely reliable assessment. Therefore, nurses should keenly observe the non-verbal vital signs indicating the painful condition and provide documentation report of such observations.

Nursing Intervention

Rationale

Implementing DSME guidance and knowledge

The Diabetes Self-Management Education is an intervention provided by American Diabetes Association that helps in addressing patient knowledge deficits regarding diabetes self-management. This intervention of guidance and knowledge will involve information about daily sugar monitor, self-management exercises, nutrition requirement of the body and required physical activity (Powers et al. 2015, p. 420). 

Guiding about nutrition therapy

Redmon et al. (2014, p. 3) indicated that obesity along with diabetic gives rise to a very critical state of disease. It is essential to reduce the obese condition of the patient by applying or guiding patient about nutrition therapy. The daily nutrition chart provides at the time of DSME intervention will help in self-management of obesity.

Educating about seven diabetic self-management techniques

The seven elementary diabetes self management techniques studied by Powers et al. (2015, p. 423) involves risk assessment, avoiding substance abuse, risk-reducing practice, daily sugar monitoring, stress managing exercise, slow walking, and avoiding harmful diet. These seven elements as education program easily explain the patient about the concept of diabetes self-management. 

Teaching patient about requirements of critical conditions

It is advisable to reach the physician in certain critical condition when the blood sugar crosses its specific limit, unconsciousness and weakness. Redmon et al. (2014, p. 5) indicated that generally patients are unaware of the critical diabetic conditions and they avoid physician visit. Therefore, it is essential to educate them regarding these critical scenarios as a part of DSME education technique.

References

DiCenso, A., Guyatt, G., & Ciliska, D. (2014). Evidence-based nursing: A guide to clinical practice. Netherlands: Elsevier Health Sciences.

Polit, D. F., & Beck, C. T. (2013). Essentials of nursing research: Appraising evidence for nursing practice. Pennsylvania: Lippincott Williams & Wilkins.

Schlag, G., & Redl, H. (Eds.). (2012). Pathophysiology of shock, sepsis, and organ failure. Berlin: Springer Science & Business Media.

Wilson, S. F., & Giddens, J. F. (2014). Health assessment for nursing practice. Netherlands: Elsevier Health Sciences.

Yoder-Wise, P. S. (2014). Leading and managing in nursing. Netherlands: Elsevier Health Sciences.

Borchers, A. T., & Gershwin, M. E. (2014). Complex regional pain syndrome: a comprehensive and critical review. Autoimmunity reviews, 13(3), 242-265. URL: https://www.ncbi.nlm.nih.gov/pubmed/24161450

Chan, C. W., & Perry, L. (2012). Lifestyle health promotion interventions for the nursing workforce: a systematic review. Journal of clinical nursing, 21(15‐16), 2247-2261.URL: https://www.ncbi.nlm.nih.gov/pubmed/22788559

Chianca, T. C. M., Salgado, P. D. O., Albuquerque, J. P., Campos, C. C., Tannure, M. C., & Ercole, F. F. (2012). Mapping nursing goals of an intensive care unit to the Nursing Outcomes Classification. Revista latino-americana de enfermagem, 20(5), 854-862. URL: https://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692012000500006

Cwik, J. (2012). Postoperative considerations of neuraxial anesthesia. Anesthesiology clinics, 30(3), 433-443. URL: https://www.ncbi.nlm.nih.gov/pubmed/22989587

Fairman, J. A., Rowe, J. W., Hassmiller, S., & Shalala, D. E. (2011). Broadening the scope of nursing practice. New England Journal of Medicine, 364(3), 193-196. URL: https://www.nejm.org/doi/full/10.1056/NEJMp1012121#t=article

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, 24(8), 668-674. URL: https://www.ncbi.nlm.nih.gov/pubmed/23228872

Holte, K. (2010). Pathophysiology and clinical implications of peroperative fluid management in elective surgery. Dan Med Bull, 57(7), B4156. URL: https://www.ncbi.nlm.nih.gov/pubmed/20591343

Kobayashi, L., Costantini, T. W., & Coimbra, R. (2012). Hypovolemic shock resuscitation. Surgical Clinics of North America, 92(6), 1403-1423. URL: https://www.sciencedirect.com/science/journal/00396109/92

Lave, R., Wilson, M. W., Barron, E. S., Biermann, C., Carey, M. A., Duvall, C. S., ... & Pain, R. (2014). Intervention: Critical physical geography. The Canadian Geographer/Le Géographe canadien, 58(1), 1-10. URL: https://onlinelibrary.wiley.com/doi/10.1111/cag.12061/abstract

Loya, J. J., Mindea, S. A., Yu, H., Venkatasubramanian, C., Chang, S. D., & Burns, T. C. (2012). Intracranial hypotension producing reversible coma: a systematic review, including three new cases: A review. Journal of neurosurgery, 117(3), 615-628. URL: https://www.ncbi.nlm.nih.gov/pubmed/22725982

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Merriman, C. D., Stayt, L. C., & Ricketts, B. (2014). Comparing the effectiveness of clinical simulation versus didactic methods to teach undergraduate adult nursing students to recognize and assess the deteriorating patient. Clinical Simulation in Nursing, 10(3), e119-e127. URL: https://www.nursingsimulation.org/article/S1876-1399(13)00241-7/abstract

Morandi, A., Brummel, N. E., & Ely, E. W. (2011). Sedation, delirium and mechanical ventilation: the ‘ABCDE’ approach. Current opinion in critical care, 17(1), 43-49. URL: https://www.ncbi.nlm.nih.gov/pubmed/21169829

Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Fischl, A. H., ... & Vivian, E. (2015). Diabetes self-management education and support in type 2 diabetes a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. The Diabetes Educator, 41(4), 417-430. URL: https://care.diabetesjournals.org/content/38/7/1372

Redmon, B., Caccamo, D., Flavin, P., Michels, R., O’Connor, P., Roberts, J., ... & Sperl-Hillen, J. (2014). Diagnosis and management of type 2 diabetes mellitus in adults. Institute for Clinical Systems Improvement. Updated July. URL: https://www.icsi.org/_asset/3rrm36/Diabetes.pdf

Stevenson, M., Gomersall, T., Jones, M. L., Rawdin, A., Hernández, M., Dias, S., ... & Rees, A. (2014). Percutaneous vertebroplasty and percutaneous balloon kyphoplasty for the treatment of osteoporotic vertebral fractures: a systematic review and cost-effectiveness analysis. Health Technol Assess, 18(17), 1-290 URL: https://www.ncbi.nlm.nih.gov/pubmed/24650687

Weingarten, T. N., Venus, S. J., Whalen, F. X., Lyne, B. J., Tempel, H. A., Wilczewski, S. A., ... & Sprung, J. (2012, January). Postoperative emergency response team activation at a large tertiary medical center. In Mayo Clinic Proceedings, 87(1), 41-49. Elsevier. URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538389/

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