CNA344: Clinical Encounter Analysis for Hypotension and Tachycardia

Read about the clinical encounter analysis for hypotension and tachycardia of a 73-year-old patient suffering from headache, dizziness, lightheadedness, and weakness. Learn about the nursing problems, goals, and related nursing actions to resolve them.

CNA344: Becoming a RN: Practice consolidation
Practice Portfolio of Evidence PART B:Clinical Encounter Analysis
Consider the
patient
situation/context
Provide an overview
of the encounter.
What happened,
how it occurred, etc
what was it that
alerted you to that
fact that you needed
to take action in the
encounter.
(150 words)
I had the opportunity to be involved in the care program of a patient named Mrs. Jane Smith, a 73 year old woman who had been
suffering from headache, dizziness, lightheadedness, and weakness and faintness. She lives alone in her own house and she had
recently lost her husband 8 months ago.
The first care activity that I had been assigned had been checking the vital signs of the patient which was represented a few notable
anomalies. First and foremost, the patient had an alarmingly low blood pressure at 95/70 mmHg. Similarly his heart rate was
accelerated at 120 beats per minute with low oxygen saturation at 93%.
On the observation being complete, it was discovered that she had persistent hypotension and due to the lack of any medical action,
the patient the patient had also developed tachycardia. Both of her conditions required immediate actions being taken to restore
homeostasis in his body and retain normal functionality. Hence, the patient Mrs Smith will require monitoring, surveillance and
treatment to address the pressing care needs and restore optimal health and wellbeing for her.
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Review:what key
information was
already available to
you and how did this
influence your
thinking? (eg:
handover, history,
charts, result of test,
assessments,
medical orders
etc.).
(150 words)
Gather:
What was the new
information you
Review:
Vital signs Observations
Temperature 36.9°C
Heart rate (HR) 120 bpm
Respiratory rate 21bpm
Blood pressure (BP) 95/65 mmHg
Oxygen saturation 93% on room air
Blood Glucose Level (BGL) 4.2 mmol
As per the clinical reasoning cycle, the first and foremost activity for the nurse to proceed for care planning after initial patient
situation consideration, is the recording, reviewing, interpreting and analysing the vital sign data and recognise the care priorities
(Dalton, Gee and Levett-Jones 2015). Critically evaluating the symptoms that Mrs smith had been exhibiting, it was discovered that
her eating and drinking patterns could be affected due to the bereavement she had been suffering after losing her husband and living
alone without any assistance. Self-imposed malnutrition and dehydration is a very common aspect observed in elderly patients,
especially for the elderly patients that are suffering from loss or bereavement. In this case, lack of appetite in the grieving elderly
individuals is associated with early signs of depression, social isolation, lack of social interaction, and most important the lack of will
to live after losing a close relative or family member (Low and Tomalia 2015). As per the vital signs that the patient is exhibiting, she
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gathered from
additional
assessment?
(150 words)
Dot points are fine
for this section
Recall:
Recall and apply
your existing
knowledge to the
above situation to
ensure you have a
broad understanding
of what is/may be
occurring before
proceeding with the
is exhibiting hypotension, dehydration and tachycardia for which she would require specialized or patient centred care.
Relevant medications (where relevant):(not included in word count)
IV paracetamol for headache
Gather:
A very important step in the care planning is thorough assessment based on the vital sign evaluation, the issues observed in the patient
include as follows-
 Condition of oral mucosa – dry mouth and furrowed tongue
 Oral intake – sips only
 Cognitive state – anxious and restless,
 Skin turgor – poor and delayed
 Level of thirst –high feeling of thirst
 Appearance- pale, cracked lips
 Urine – dark, cloudy, smelly
 Last bowel motion- 2 days ago, small amount
Recall:
This is the step where the nurses are required to recall, assess and evaluate the exact conditions that the patient have been suffering
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rest of the cycle.
What was telling
you that the
encounter was
presenting you with
a problem that
required resolution?
(200 words)
Use scholarly,
evidence-based
literature/clinical
guidelines and/or
policy/NSQHS
materials to
substantiate your
from. The three major issues that the patient in this case is suffering from includes hypotension, dehydration and slight tachycardia.
Hypotension can be defined as the clinical state where the patients are suffering from a condition where the systolic blood pressure is
less than 90 mmHg and diastolic blood pressure is less than 60 mmHg for a persistent period. Hypotension is a very common
condition for elderly population and for older adults that are suffering from bereavement or loss are often prone to neglecting self-care
needs and ignoring normal eating habits (Hooper et al. 2015). In this case as well, Jane had been suffering from depression and
overwhelming grief which led her to abandon her normal eating habits which in turn led to dehydration and BGL level drop resulting
in the hypotension in the patient. In this case, if her hypotension persists there is a considerable chance of the patient going into
hypovolemic shock, which if not addressed on an urgent basis can even cause death of the patient. Hence, in this case, it will be the
foremost priority of the patient receiving care would be to raise her blood pressure to 120/80 mmHg within the next 24 hours.
The next most important health issue or challenge for Jane is the tachycardia. It has to be mentioned that she suffered a significant
drop in the blood pressure which indicates at the chance of blood volume reduction through the dehydration and reduction in the
blood flow. This is also known as reflex tachycardia which is caused by the shift in blood volume due to dehydration and unexpected
change in the blood flow. The oxygen deficiency in the body due to hypotension also leads to risk of tissue necrosis which in turn
causes high cardiac output to compensate for the reduced oxygen supply to the tissues. Hence, the next most important care priority
for Jane would be reducing her heart rate to normal level (Kataria and Jacobson 2018).
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discussion
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Process
Information
Interpret, relate and
infer from the
information
gathered to
demonstrate an
overall
understanding of the
clinical encounter to
determine the two
main nursing
problems.
Interpret, Relate and Infer:
Applying best practice knowledge about the vital signs, further assessment data and symptoms by interpreting and evaluating the
collected cues, it can be inferred that hypotension and tachycardia are the two main nursing problems for Jane. The table below
demonstrates normal versus abnormal clinical signs that can be compared to infer the nursing problem (Dalton, Gee and Levett-Jones
2015).
Normal Data Abnormal Data
 Temperature 36.9°C
 Respiratory rate 21 breaths per
minute
 SpO2 97% on room air
 BGL 4.4 mmol
 Heart rate 120 beats per minute
 Blood pressure 95/70 mmHg
 dry mouth
 Cognitive state – anxious and restless
 Skin turgor – poor and delayed
 Level of thirst – extreme thirst
 Appearance- pale, cracked lips
 Oxygen saturation: 93%
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(400 words)
Predict
What could/would
have happened in
your encounter if
you were to have
taken NO action and
why?
(100 words)
Use scholarly,
evidence-based
literature/clinical
guidelines and/or
policy/NSQHS
materials to
Relating:
The next step is to assimilate and compare all the cues together and develop a relationship between the above most relevant abnormal
data and clinical findings. As per the investigation and analysis so far, Mrs Jane Smithhad been exhibiting signs oftachycardic due to a
hypotension which had chances to develop into a hypovolemic shock. Hypovolaemia is a low blood volume due to low extracellular
fluid volume which can be strenuous to the heart, causing cardiac overload. During dehydration, the blood volume circulating through
a body decrease. As a result the heart rate is escalated to compensate for the oxygen deficiency. Also, as Mrs Jane had been
dehydrated, the sodium retention further restrictedthe blood circulationresulting in high probability of hypovolemic shock (Masento et
al. 2014).
Infer:
From the detailed analysis and interpretation of the collected cues, it can be inferred that Mrs Bright can be primarily diagnosed with
severe hypotension and associated reflex tachycardia.
The impact of the hypotension which was unaddressed for at least more than 24 hours generated cardiac overload. Hence, addressing
the hypotension will inevitably address the tachycardia as well. Care is needed to be taken to address the dehydration that the patent
had been suffering as well.
Moreover, She been febrile along with having low blood-pressure, increased heart rate and decreased urine output; she could be
queried for sepsis (Rabinow and McKee 2015).
Predict:
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substantiate your
discussion
The prediction for the present conditions that Mrs. Jane Smith had been suffering from includes cardiac arrest and hypovolemic
shock. As the patient had considerably elevated heart rate due to low blood pressure, fluid volume alterations, hypovolemic shock and
low oxygen saturation. Hence, the cardiac overload if not addressed appropriately can enhance the risk of cardiac arrest.Similarly, the
hypotension, dehydration, and fluid volume imbalance, if not addressed appropriately can also lead to hypovolemic shock. Hence, the
two most notable predictions on deterioration of the patient include hypovolemic shock and cardiac arrest (Yun, Kim and Kim 2015).
Identify the
Problem/s
List in order of prioritytwokey nursing problems that required resolution (not included in word count)
Problem 1 Hypotension
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Problem 2 Tachycardia
Establish Goals &
Take Action
Work through the
two nursing
problems identified
and establish one
goal and then
rationalise with
scholarly, evidence-
based
literature/clinical
guidelines and/or
policy/NSQHS
materials the related
nursing actions you
Problem 1 Goal Related nursing actions Rationale
Hypotension
 mean Arterial Pressure
would be minimum 65
mmHg
 heart rate would be
below 100 bpm
 urine output would be
below 40 mls
 As per the physician’s
instruction,
administration of the
electrolyte fluid and
medication to reduce
hypotension (Xu et al.
2017).
 Assessment of IV
cannula site and lines
for healthy patient on
the regular basis.
 Monitoring the vital
signs of the Mrs. Smith
as well as oxygen
saturation level.
 In older patient , the
prevalence of the
hypotension led to co
morbidity and
therefore,
administration of fluid
and medication should
be recommended
 Daily assessment of
IV cannula site and
lines help in reducing
the IV complications
such as blood stream
infection and swelling
(Budyono et al. 2016).
Monitoring vital signs will
help in gaining information of
abnormal changes in the body
and improvement help in
giving idea of rehydration
(Ricci, De Caterina and
Fedorowski 2015
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did/would undertake
(125 words for each
rationale section).
Other sections not
included in word
count.
 )
Problem 2 Goal Related nursing actions Rationale
tachycardia  reduction of heart rate
to the normal
 reducing blood clot
 Provide oxygen as per
nasal cannula at 4L/
min.
 Administration of
blood thinner (anti-
coagulant) such as
heparin under
supervision of with
doctors.
 Monitoring the vital
signs
 Provide oxygen as per
nasal cannula at 4L/
min is effective for
reducing the
tachycardia since it
helps in proving
oxygen in clotted
ventricles and
normalize heart rate
(Sapontis et al. 2015)
 It is often observed that
the patient has blood
clot due to tachycardia.
Therefore,
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anticoagulant would
help to prevent further
blood clot and high risk
of stroke
(Cvpharmacology
2019).
Evaluate outcomes
Evaluate the
outcomes of your
clinical encounter
including
effectiveness of the
Electrolytic fluid given to the Mrs. smith, she reported that she was not feeling thirsty and her heart rate improved to 95 bpm, urine
rate is 36 ml/ hr , MAP is increased to 89 mmHg as Bp was elevated to 120/ 70 mmHg.
Her symptoms of headache, light headedness, dizziness and fainting resolved to some context. She reported to feel better about her
health. Thus, it can be concluded from the evaluation that her fluid status has improved after fluid administration. However, she would
still require clinical assistance and routine monitoring in order to evaluate further changes. Accumulated evidence highlighted that in
elder patient, even after post dehydration treatment involving hemodynamic stability, a considerate number of individuals are at
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care provided with
supporting
evidence-based
literature
(100 words)
*Do not ‘reflect on
new learning’ in this
section. This will
occur in your next
assessment (Part C).
higher rate of developing psychological disease. Thus, in order to improve quality of life, with the compliance of The National Safety
and Quality Health Service (NSQHS) , nurses should provide care to the patient.
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References:
Budyono, C., Setiati, S., Purnamasari, D. and Rumende, C.M., 2016. The proportion of orthostatic hypotension and its relationship with hba1c levels in elderly
patients with diabetes. Acta Med Indones, 48(2), pp.122-8.
Cvpharmacology., 2019. CV Pharmacology | Beta-Adrenoceptor Antagonists (Beta-Blockers). [online] Available at:
https://www.cvpharmacology.com/cardioinhibitory/beta-blockers [Accessed 7 Jan. 2019].
Dalton, L., Gee, T. and Levett-Jones, T., 2015. Using clinical reasoning and simulation-based education to'flip'the Enrolled Nurse curriculum. Australian
Journal of Advanced Nursing, The, 33(2), p.29.
Gibbons, C.H., Schmidt, P., Biaggioni, I., Frazier-Mills, C., Freeman, R., Isaacson, S., Karabin, B., Kuritzky, L., Lew, M., Low, P. and Mehdirad, A., 2017.
The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine
hypertension. Journal of neurology, 264(8), pp.1567-1582.
Hooper, L, Abdelhamid, A, Attreed, NJ, Channell, AM, Ranson, SC, Campbell, WW, Chassagne, P, Culp, KR, Fletcher, SJ, Fortes, MB, Walsh, NP, Fuller, N,
Gaspar, PM, Gilbert, DJ, Smith, AC, Ward, S, Heathcote, AC, Kafri, MW, Kajii, F, Lindner, G, Mack, GW, Mentes, JC, Merlani, P, Needham, RA,
OldeRikkert, MGM, Perren, A, Powers, J, Ritz, P, Rowat, AM, Sjöstrand, F, Stookey, JJD, Stotts, NA, Thomas, DR, Vivanti, A, Wakefield, BJ, Waldréus, N,
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Potter, JF and Hunter, P 2015, ‘Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people’,
Cochrane Database of Systematic Reviews, vol. 2015, no. 4.
Kataria, H and Jacobson, M 2018, ‘Assessment and management of hypotension in the elderly patient’, Journal of Emergencies, Trauma & Shock, vol. 11, no.
3, pp. 221–22. Levett-Jones, T, Hoffman, K, Noble, D, Roche, J, Dempsey, J, Jeong, SYS, Norton, CA & Hickey, N 2010, ‘The “five rights” of clinical
reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically “at risk” patients’, Nurse Education Today, vol. 30, no.
6, pp. 515–520.
Low, P.A. and Tomalia, V.A., 2015. Orthostatic hypotension: mechanisms, causes, management. Journal of Clinical Neurology, 11(3), pp.220-226.
Masento, NA, Golightly, M, Field, DT, Butler, LT and van Reekum, CM 2014, ‘Effects of hydration status on cognitive performance and mood’, The British
Journal Of Nutrition, vol. 111, no. 10, pp. 1841–1852.
Rabinow, B. and McKee, J., Baxter Healthcare SA and Baxter International Inc, 2015. Methods for treating tachycardia and/or controlling heart rate while
minimizing and/or controlling hypotension. U.S. Patent 9,084,763.
Ricci, F., De Caterina, R. and Fedorowski, A., 2015. Orthostatic hypotension: epidemiology, prognosis, and treatment. Journal of the American college of
cardiology, 66(7), pp.848-860.
Sapontis, J., Christopoulos, G., Grantham, J.A., Wyman, R.M., Alaswad, K., Karmpaliotis, D., Lombardi, W.L., McCabe, J.M., Marso, S.P., Kotsia, A.P. and
Rangan, B.V., 2015. Procedural failure of chronic total occlusion percutaneous coronary intervention: insights from a multicenter US registry. Catheterization
and Cardiovascular Interventions, 85(7), pp.1115-1122.
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XU, J.J., Lin, Q.Z., Dong, Y.F., Feng, F.G., Duan, X.Y., Sun, N.N., Quan, X.X. and Xie, Q.Z., 2017. Exploration of Prevalence and Risk Factors for
Orthostatic Hypotension in Elderly Hypertension Patients. Chinese Circulation Journal, 32(10), pp.989-993.
Yun, S.H., Kim, J.H. and Kim, H.J., 2015. Comparison of the hemodynamic effects of nitroprusside and remifentanil for controlled hypotension during
endoscopic sinus surgery. Journal of anesthesia, 29(1), pp.35-39.
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