Clinical Case Presentation and Management Plan

This assignment involves the clinical assessment and management of a patient presenting with signs of hypovolemic shock, including rapid breathing rate, dilated pupils, and distended abdomen. The patient has a history of atrial fibrillation and arthritis knees, and is taking warfarin and diclofenac acid medication. The clinical signs indicate internal gastrointestinal bleeding, possibly due to an abdominal aortic aneurysm (AAA). The ABCDE approach is recommended for the assessment and management of this patient's condition.

Running head: BACHELOR NURSING ASSIGNMENT
Bachelor nursing assignment
Name of the Student
Name of the University
Author note

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Part A
In the given case study, Maureen Hardy, a 77-year-old woman had two episodes of
haematemesis and she vomited blood. The case presentation shows that among the four types of
shock, the patient suffers from hypovolemic shock, as there is loss of blood due to
gastrointestinal bleeding. There is acute external blood loss and severe gastrointestinal bleeding
which is the main cause for the hemorrhagic shock. This shock results from significant internal
bleeding into abdominal cavities. Hypovolemic shock is secondary to hemorrhagic shock in
which there is rapid blood loss.
The main cause for the patient’s blood loss may be due to abdominal aortic aneurysm
(AAA) as she had a slightly distended abdomen (Kent, 2014, p.2101-2108). Hemorrhagic shock
occurs when there is reduction of tissue perfusion that results in inadequate oxygen delivery and
nutrients that are necessary for cellular function (Kobayashi, Costantini & Coimbra, 2012,
p.1403-1423). There is heavy bleeding, there is inadequate blood flow to the organs, and the
symptoms of hypovolemic shock occur. External bleeding occurs which the symptom of internal
bleeding. The patient in the case study has irregular heart rate of 120bpm and blood pressure of
80mmHg. The respiratory rate is 28bpm and capillary refill time is >4sec with unreadable SaO2.
The body temperature is also low (36.5°C) and pupils are dilated. All thse signs and symptoms
occur in hypovolemic shock due to acute blood loss.
The heart rate of Maureen Hardy is 120bpm that shows tachycardia condition with
moderate hypovolemia (III) considered as stage III hypovolemia shock. This condition occurs,
as there is reduction of blood volume in circulation to the lower venous return that is irrespective
of the cause. In hypovolemia, there is arterial hypotension that is severe and there is

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compensatory systemic catecholamines release promoting peripheral vasoconstriction,
tachycardia and increase in cardiac contractility. Tachycardial condition gives rise to increase in
myocardial oxygen demand along with reduction in tissue perfusion that might result in
myocardial failure. Therefore, the ECG of the patient showed sinus tachycardia (Vincent & De
Backer, 2013, p. 1726-1764).
Another vital sign is blood pressure in hypovolemia below 90mmHg that is 80mmHg
that is markedly decreased in hypovolemia. The reason behind this is vasoconstriction that
decreases perfusion to pancreas, kidney, liver and spleen. There is narrow pulse rate in this shock
as there is decreased cardiac output and an increase in peripheral vascular resistance. There is
decrease in venous volume due to blood loss and so the sympathetic nervous system attempt to
maintain or increase the falling blood pressure through the mechanism of systemic
vasoconstriction. Therefore, the blood pressure of the patient is 80mmHg due to vasoconstriction
that is not normal and requires further assessment of the skin colour, respiratory rate and mental
status (Schlag & Redl, 2012, p.401-405).
The respiratory rate of the patient is also abnormal that indicate tachypnea (rapid
breathing) 28 bpm as the normal rate is 12 to 20 bpm. There is shallow breathing in hypovolemia
shock as there is increase in blood loss that can increase from 20 to 30 percent. There is
abnormal breathing rate of patient that raises the breaths per minute (Buerke et al., 2011, p.73-
83). The capillary refill time (CRT) is less than two seconds in a normal person that is measured
by pressing the sternum with thumb or finger for five seconds that notify the time when the
colour of the skin return to normal after the pressure is released. This CRT is more than 4
seconds in the patient that indicates the dehydration and less amount of blood flow to the tissues.
This prolonged CRT indicates signs of shock, dehydration and decrease in peripheral perfusion.

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This increase in CRT made the skin turn pale, cool, sweaty and drowsy in the patient when the
nurse assessed the skin colour (Pickard, Karlen & Ansermino, 2011, p.120-123).
The body temperature is also 36.5°C indicates massive drop in the core body temperature
of the patient. This occurs due the body went to hypvolemic shock with acute external bleeding
and condition of hypothermia. At the same time, the mental status is also taken into
consideration where it is showed that patient responded to verbal stimuli on "alert, voice, pain,
unresponsive" (AVPU) scale. The patient responded to verbal stimuli indicated that she has some
kind of respond when the nurse speaks and pupils are dilated that is abnormal response to shock
called mydriasis (Meyer et al., 2013, p.93-100).
After the identification of the vital signs of the patient in diagnosed with hypovolemic
shock, it is important to relate each sign and symptom to ABCDE approach for better
understanding. This approach explains A-airway, B-breathing, C-circulation, D-disability and E-
exposure. Airway in hypovolemic shock is the assessment of airway obstruction in the upper and
lower airways (Thim et al., 2012, p.117). This case study indicates upper airway obstruction as
the patient vomits blood and as a result, there is loss of blood from the blood indicating
haemoglobin of 9g/dL. Breathing is assessed through looking for the sweating, skin colour,
abdominal breathing, depth and rate of breaths along with equality in chest movements (Frost &
Wise, 2012, p.5677). In the given patient condition, although there is bilateral chest movement,
abnormal rapid breathing occurs in the patient with normal depth of breathing. In all cases of
hypovolemia shock, circulation is assessed in the patient. In Maureen, circulation is indicated in
a way where there is uncontrolled external bleeding through vomiting, tachycardia, skin is cool,
pale and sweaty (Pearson, Round & Ingram, 2011, p.387-389). For the circulation assessment,
the capillary refill is low; blood pressure is low with decrease in pulse pressure indicating arterial

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vasoconstriction. There is also decreased tissue perfusion and reduced pulse rate. Disability
approach includes examination of pupils (shape, size and reaction to light) on the AVPU scale.
In the given case study, the patient has dilated pupils and only responded to verbal stimuli
indicated Voice on the AVPU scale. Exposure is the exposure of full body for the physical
examination ensuring dignity and respect with focused assessment of dorsal and frontal aspects
of the body (Estes, 2013, p.285-289). In this, vital observations are taken into consideration like
blood pressure, fluid balance, medical history, haematology and reassessment of ABCs to
monitor the vital parameters of the patient. The patient history is also assessed comprising of
medications like beta-blockers, Warfarin. Among all these, for the physical assessment, ABC
approach- airway, breathing and circulation is considered in case of hypovolemic shock (Cap &
Hunt, 2015, p.96).
Part B
ISBAR Clinical Handover
Identify the client:
The patient is a 77 year-old patient named Maureen Hardy who was sent to
GP for the review as she had encountered two episodes of haematemesis
while she was at home. After she reached the ward, she vomited blood and
had a sightly distended abdomen.
Situation:

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Currently, the patient is vomiting blood and her skin appears pale, cool and
sweaty. She is only responding to verbal stimuli as recorded in AVPU scale.
Her vital observations shows that she is having low blood pressure
(80mmHg), high heart rate (120bpm and irregular), abnormal respiratory
rate (28bpm) and slow capillary refill time (>4secs). Her pupils are dilated
and distended abdomen. Her depth of breathing is normal and equal
bilateral chest movement. It is also evident from the observations that she
is suffering from tachycardia and tachypnoea. She also has a low core body
temperature (36.5°C).
Background:
There is no such diagnosis done for the patient. However, the patient came
to the hospital after she had two episodes of haematemesis while she was
at home. Then she was said to visit her GP and after she reached the ward,
four hours later, she vomited blood and her skin appeared pale, cool and
sweaty. She was only responsding to verbal stimuli and her pupils were
dilated. Her bilateral chest movement was equal with normal depth of
breathing. However, she had a slightly distended abdomen. On
examination, chest x-ray was normal and ECG showed tachycardia
condition. She takes medication; diclofenac acid 50mgs PO for arthritis
knees and warfarin 2mgs PO for the atrial fibrillation (INR 2.7)

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Assessment:
The current condition of patient shows a lot of blood loss with increased
breathing rate, low breathing rate, abnormal rapid breathing, unreadable
oxygen saturation levels, low core body temperature and slow capillary
refill time. Due to massive blood loss, the haemoglobin is 9g/dL. The
patient also showed equal chest movement and normal depth of breathing.
However, the patient’s abdomen is slightly distended,
The clinical signs indicate hypovolemic shock due to internal
gastrointestinal bleeding. Due to severe GI bleeding, there might be acute
blood loss from the body leading to hemorrhagic shock. The vital signs
indicate that the patient is suffering from hypovolemic shock might be
because of abdominal aortic aneurysm (AAA).
There is reduction of tissue perfusion that results in inadequate oxygen
delivery and there is inadequate blood flow to the organs, and the
symptoms of hypovolemic shock occur.
Recommendations:
After the handover, it is important to stop the external bleeding and acute
blood loss. The multidisciplinary considerations comprises of the ABCDE
approach that would be helpful for the appropriate assessment of the
patient indicating hypovolemic shock.
Airway in hypovolemic shock is the assessment of airway obstruction in
the upper and lower airways.
Breathing is assessed through looking for the sweating, skin colour,
abdominal breathing, depth and rate of breaths along with equality in
chest movements.
Circulation assessment, the capillary refill is low; blood pressure is low
with decrease in pulse pressure indicating arterial vasoconstriction.
Disability approach includes examination of pupils (shape, size and
reaction to light) and voice on AVPU scale.
Exposure is the exposure of full body for the physical examination
ensuring dignity and respect with focused assessment of dorsal and frontal
aspects of the body.

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References

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Buerke, M., Lemm, H., Dietz, S., & Werdan, K. (2011). Pathophysiology, diagnosis, and
treatment of infarction-related cardiogenic shock. Herz, 36(2), 73-83. Doi:
10.1007/s00059-011-3434-7
Cap, A., & Hunt, B. J. (2015). The pathogenesis of traumatic coagulopathy. Anaesthesia, 70(s1),
96. Doi: http://onlinelibrary.wiley.com/doi/10.1111/anae.12914/full
Estes, M. E. Z. (2013). Health assessment and physical examination. Cengage Learning.
Frost, P. J., & Wise, M. P. (2012). Early management of acutely ill ward patients. BMJ, 345,
e5677. Doi: 10.1136/bmj.e5677
Kent, K. C. (2014). Abdominal aortic aneurysms. New England Journal of Medicine, 371(22),
2101-2108. Doi: 10.1056/NEJMcp1401430
Kobayashi, L., Costantini, T. W., & Coimbra, R. (2012). Hypovolemic shock
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Meyer, M. A., Ostrowski, S. R., Overgaard, A., Ganio, M. S., Secher, N. H., Crandall, C. G., &
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Pickard, A., Karlen, W., & Ansermino, J. M. (2011). Capillary refill time: is it still a useful
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Schlag, G., & Redl, H. (Eds.). (2012). Pathophysiology of shock, sepsis, and organ failure.
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Thim, T., Krarup, N. H. V., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial assessment
and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE)
approach. International journal of general medicine, 5, 117. Doi: 10.2147/IJGM.S28478
Vincent, J. L., & De Backer, D. (2013). Circulatory shock. New England Journal of
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