Pathophysiology and Nursing Goals for Post-Operative Hypovolemia in Acute Care

This article discusses the pathophysiology of post-operative hypovolemia and nursing goals for its management in acute care. It explains the importance of early detection and proper hydration management in preventing complications. The article also highlights the risks associated with vacuum drains and surgical site infections.

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Name of the Student
Name of the university
Author’s note

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Pathophysiology of Eleanor’s post-operative hypovolemia
Hypovolemia is a clinical condition in which a rapid loss of the body fluid takes place,
which might cause a multiple organ failure due to the inadequate circulating volume and
subsequent inadequate perfusion. Hypovolemia can be referred to as decrease in the volume of
the blood relative to a normal sized vascular compartment (Gann & Drucker, 2013).
Hemorrhagic shock can also occur due to acute internal blood loss in the thoracic or the
abdominal cavity. Furthermore, Eleanor has undergone resection of the tumor under anesthesia.
It has to be mentioned that anesthesia related vasodilation can be the primary cause of relative
hypovolemia (Noel-Morgan & Muir, 2018). Hence prolonged effect of anesthesia might have
caused hypovolemia in the patient. Vasodilation associated with hypovolemia is associated with
the increased venous compliance, decreased venous return and a reduced response to the
vasoactive substances. Depending upon the status of the patient the hypovolemia might remain
clinically undetected with the impending consequences due to the impaired oxygen delivery and
the tissue perfusion (Gann & Drucker, 2013). The hematocrit count and the low concentration
of the hemoglobin indicates towards hemorrhagic shock that might have occurred. Isovolemic
anemia can also occur if the blood transfusion is not available, which is characterized by a
decreased hemoglobin content. Hypovolemia causes a lowered cardiac output and hypotension
by decreasing the preload, which can be related to the low blood pressure obtained in the
subjective values of the Eleanor- BP 90/54. Again, the heart rate in hypovolemic shock increases
which can be observed form the vital signs of this patient. Low urinary sodium is found in the
hypovolemic patients because the kidney attempts for the conservation of the sodium and water
for the expansion of the extracellular volume.

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Trauma can be associated with the hypovolemia, with the profuse attendant blood loss.
Blood loss has been associated with the traumatic fracture or resection of malignant tumors.
How does the body compensate it physiologically
The body compensates with the increased sympathetic tone causing an increased heart
rate, increased cardiac contractility, and peripheral vasoconstriction. The initial changes that can
be seen in the vital signs is the increased diastolic pressure along with a narrowed pulse pressure
(Taghavi & Askar 2018). A volume status continues to decrease and the systolic blood pressure
drops. Again there are some other compensatory mechanism that a body employs to deal with the
hypovolemic shock. The mechanisms includes the baroreceptor reflexes, the chemoreceptor
reflexes, the circulating vasoconstrictors, the renal absorption of the sodium and water ,
activation of the thirst mechanism and the reabsorption of the tissue fluids (Gulati, 2016).
A body can quickly sense a reduction of the arterial blood pressures by the help of the
arterial and the cardiopulmonary baroreceptors and then activates the sympathetic adrenergic
system for stimulating the heart (increase the contractility and the heart rate) and the constriction
of the blood vessels. This causes an increase in the systemic vascular resistance and the arterial
pressure. Hence the cardiac output is redistributed from the less important organ to the brain
(Gulati, 2016). The reduced blood flow caused due to the vasoconstriction and the reduced
arterial pressure causes systematic acidosis that is normally sensed by the chemoreceptors.
The combined effect of the arterial hypotension and the sympathetic activation causes the
activation of the humoral compensatory mechanism. The sympathetic stimulation of the adrenal
glands stimulates the release of the catecholamines in to the blood that reinforces the impacts of
sympathetic activation of the vasculature and the heart (Gulati, 2016). The kidney releases more

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renin after the hemorrhage. It leads to an increased circulating level of the angiostenin II and
aldosterone. It causes vascular contraction, increased sympathetic activity and stimulation of the
release of vasopressin.
Hypotension, combined with the contraction of the precapillary resistance vessels causes
a fall in the capillary hydrostatic pressure (Lonjaret, Lairez, Minville & Geeraerts, 2014). This
pressure normally facilitates the filtration of the fluid from the blood across the capillary
endothelium and in to the interstitial space (Thomovsky & Johnson, 2013). As the capillary
hydrostatic pressure is reduced, less amount of fluids leaves the capillaries. When the pressure
falls sufficiently low , net absorption of the fluid can occur from the tissue interstitium back in to
the capillary plasma (Thomovsky & Johnson, 2013). The blood plasma volume is increased,
causing the hemodilution of the blood and therefore the hematocrit falls in response to the fluid
shift. This can be related to fact that the Haematocrit (HCT) range was 0.36 , which slightly less
than the standard value.
Identification of the priority problems in Eleanor
Eleanor has returned to the ward after a right hemicolectomy for a poorly differentiated
adenocarcinoma of the ascending colon. The four clinical priorities for Eleanor has been stated
below:-
 Low blood pressure – The assessment data of Eleanor in the post-operative period clearly
indicates he incidence of hypotension in the patient. Hypotension in Eleanor might have been
caused due to hypovolemia occurred after the patient had returned from the surgery.
Hypovolemia has been found to be causing a low cardiac output and hypotension, which can
occur due to the loss of the circulating blood volume after the hemorrhage. Hypotension

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might again be caused after a patient had been under continued anesthesia (Noel-Morgan &
Muir, 2018). Hypotension in the patient might give rise to the syncope. It can be seen that
Eleanor’s urine output is high, which again might have caused the blood pressure to drop.
 Indwelling catheter (IDC) on hourly urine measures 15 – 20ml/kg/hr- The normal urine
output of a patient s 1-2 ml/kg/hr. As per the subjective value of Eleanor’s vital signs, the
indwelling catheter (IDC) on the hourly urine measured the 15-20ml/kg/hr, which is much
higher than the normal value. This might lead to high urine output. Polyuria can quickly
deplete the intravascular volume of the patient. This might cause hypotension and organ
hypoperfusion. This value can again be linked to the hypovolemia low blood pressure in
Eleanor (Blackham, Farrah, McCoy, Schmid & Shen, 2013). Patients with high urine output
had displayed various signs of intravascular volume depletion such as delayed capillary refill,
hypotension and tachycardia. Hence early recognition followed by the replacement of the
volume losses with the simultaneous efforts for the identification of the cause can be useful
to mitigate this clinical condition.
 Vacuum drains – there is a high risk of the infection due to the vacuum drains used after the
surgical procedures. Excessive fluid accumulation in the drains might lead to bacterial
proliferation. The drains can upsurge the risk of infection via the retrograde bacterial
migration. Normally, the drains are removed when a negligible amount is been draining.
 Midline laparotomy incision with an occlusive dressing- It should be mentioned, that the
occlusive dressing cannot be removed unless approved by the surgeon. Two complication of
the surgical wounds are infection and wound dehiscence (Cara, 2018). It is necessary to
follow the post-operative wound review, occurrence of hematoma, serum, separation of the
wound sedges or the occurrence of purulent wound discharge from the wound discharge sites

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(Sasma et al., 2016). If the dressings of Eleanor’s wound are not managed then it can cause
inflammation of the wound. Dressings are an important component of the post operative
wound management. If no update is taken from the surgeon regarding the change of the
wound dressing, then it might lead to maceration of the wound.
Nursing goals
The nursing goals are meant to help the individuals, groups or the communities to reach
an optimum state of wellbeing, by the restoration, maintenance and promotion of the health. The
nursing goals has to be patient specific, measurable, achievable and has to be completed within a
specific time frame.
Nursing goals for low blood pressure:
The nursing goals is the assessment of the low blood pressure and the underlying case of
the low blood pressure and using proper approaches for controlling the postoperative
hypotension. A nurse can diagnose the low blood pressure by taking the medical history and
physical examination. Ephedrine and phenylephrine is the first line of treatment of the
intraoperative hypotension at the time of general anesthesia (Taghavi & Askari, 2018).
Nursing goals for the reducing the higher urine output of the patient:
One of the nursing goal is to measure and manage the fluid balance of the body, ensuring
that the patient is properly hydrated. This is because the urine output is an important marker of
the kidney function and an independent marker of the serum creatinine.

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Nursing goals about the management of the vacuum drains
The nursing goal regarding the management of vacuum drains is to mitigate the risk of
infections, while changing the drains. Drains are a common feature of the postoperative surgical
management and some of the complications related to the drains are infections, leakage and
blockage.
Nursing goals regarding the surgical site
One of the important goal regarding the incision site is to reduce the risk of infections at
the incision site. The incision site is vulnerable to infections and causes accumulation of puss and
formation of edema, hence, it the duty of the nurses to do a regular assessment of the surgical
site.
Evidence based rationale of the nursing goals
The two nursing goals that has been chosen for the discussion is the post-operative management
of the hypotension and management of the surgical site.
Management of the blood pressure is an important nursing goal for Eleanor. This is due
to the fact that the occurrence of hypotension can be because of multiple reason such anesthesia
or due to hypovolemia. Hypovolemia in the patient can be caused due to the hemorrhage (van
Waes et al., 2016). Hence it is essential for the nurses to understand any incidence of internal
bleeding as delay in taking appropriate and timely measures can bring about mortality in the
patient. Excessive lowering of the blood pressure might cause life threatening conditions and
hence it is necessary to do an early detection of the hypotension for preventing the progression,
mortality and morbidity due to, multisystem organ failure. In accordance to this, it can be stated
that hypotension due to the hypovolemia can lead to tachycardia, decreased skin turgor,

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mesenteric or coronary ischemia (van Waes et al., 2016). Severe sock might decrease the tissue
perfusion, which can lead to cellular tissue perfusion and death. Hence one of the prime goal is
to assess he vital signs of the patient. One of the important step to accomplish the nursing goal is
to recognize the etiology of the shock condition.
Mitra, Roy, Bhattacharyya, Yunus & Lyngdoh, (2013), have stated that proper hydration
management of the patient and pharmacological management in patients can mitigate the
occurrence of post-operative hypotension and its related complications
According to a dose respondent study of the prophylactic infusion of the phenylephrine
and the ephedrine in the prevention of the hypotension in the perioperative period has
demonstrated a potency ratio of 81:1. Both the ephedrine and phenylephrine has been found to be
effective against anesthesia induced hypotension.
The rational for choosing management of the laparoscopic surgical site infection for this
patient is due to the fact a large number of complications might arise due to infections in the
surgical site. Although laparoscopic surgery has brought about a paradigm shift in approach to
the modern surgical care. The emergence of the rapid atypical mycobacteria with the multidrug
resistance has compounded the problem of infections in the surgical site (Anderson et al., 2016).
Despite of the advances in the field of the antimicrobial agents, surgical techniques, operating
room ventilation, the incidence of the surgical site infection still remains. The infection rate had
been reported to be 8% with 89% of the infections occurring after laparoscopic cholecystectomy,
and 11% has been noted after laparoscopic appendectomy. A seroma might form after a
laparoscopic surgery and hence it is necessary to manage the surgical drains for the prevention of
the accumulation of the fluids. If the fluids are not drained properly then the patient might

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develop abscess, putting the patient at the risk of developing a sepsis. According to Karthik,
Augustine, Shibumon, and Pai,(2013), 30 % of the patients develop seroma due to the improper
drainage of the fluids from the surgical site. Formation of the incisional hernia at the port site
after a laparoscopic surgery can be another important complication after a laparoscopic surgery
(Agaba, Rainville, Ikedilo & Vemulapali, 2014). The dehiscence of the wound can be prevented
by regular inspection and the dressing of the wound.
Since of the effective management of the surgical wound is to manage the wound
dressing, ensuring that the surgical site is not moist with the exudates, free form any clinical
infections, free form toxic chemicals, fibers released form the dressing. According to Itatsu et al.,
(2016), 60 % of the surgical site infection has been found to be due to the lack of proper dressing
materials.
Conclusion
In conclusion it can be said that the post-operative hypotension can pose serious threats to
Eleanor’s condition. The predisposing factor for the hypotension can be the surgery associated
hypovolemia or due the anesthetics given at the time of the surgery. Furthermore, nursing
priorities involve the higher urine output and the complications related to surgical drains and the
incision site. The core principle of nursing goals is a continuous and monitoring of the
underlying pathophysiology of each of the conditions, such that specific nursing interventions
can be opted.

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