CLINICAL REASONING AND DETERIORATING PATIENT.

Running head: CLINICAL REASONING AND DETERIORATING PATIENT
CLINICAL REASONING AND DETERIORATING PATIENT
Name of the Student
Name of the University
Author note

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CLINICAL REASONING AND DETERIORATING PATIENT
Patient situation
82 years old, Mary Smith has been admitted in a general surgical department
following surgery for left total knee replacement under general anaesthesia 6 hours
ago.
Cues/information
Mary weighs 100 kilo -grams, she also has fatty liver disease with moderate
enlargement and essential hypertension. She has diabetic neuropathy in both feet
with intermittent mild neuropathic pain and no neurological deficit.
Mary is currently on beta blockers for her hypotension and one hour ago her BP
was 123/70 mmHg, radial pulse 55, RR 18, SpO2 96%, FiO2 0.21, T 36.2,
peripheral capillary refill 2 seconds, warm digits. She is fully alert with GCS of 15,
her surgical wound dressing is dry with no ooze and she has not accessed her PCA
in the past hour. Mary feels lightheaded and she stated she has 7/10 pain in her Left
knee. She has less appetite and has tried sips of water and she feels nauseated.
Upon checking Mary has an 18G IV catheter in her right hand and isotonic saline
running at 80mL per hour via a pump with 200mL remaining in the IV bag,. The
PCA circuit is attached to this line. Mary’s vital signs are now BP 105/56mmHg,
radial pulse 66 regular, RR20, SpO2 93%, FiO2 0.21, T36.4 tympanic.
BGL11.5mmol/L, Peripheral capillary refill is 3 seconds plus pale cool digits.

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CLINICAL REASONING AND DETERIORATING PATIENT
Mary is taking beta blocker which may have influenced her drop in blood pressure
because they cause vasodilation (Parati et al., 2013). Mary has not accessed her
PCA in the past hour and she has pain score of 7/10 which can result in stimulation
of stress response therefore an increase in heart rate and decrease in oxygen level.
Her capillary refill has just increase from 2 seconds to 3 seconds which in her case
may evidence Cold temperatures, Peripheral vasoconstriction, Shock, Dehydration
and may also be the cause of her decrease in oxygen level (Parati et al., 2013).
Processing information
For a person with a history of Hypertension Mary’s blood pressure is very low and
she is now showing signs of tachycardia and hypoxia (Parati et al., 2013). She is
afebrile and her BGL is within normal range for type 2 diabetic patients which
leaves the nurse more concerned about her hypotension, capillary refill, pain and
tachycardia.
Because Mary just had surgery her low blood pressure may be a result of blood
loss. Mary might be suffering internal bleeding which refers to bleeding that occurs
inside the body that is not seen from the outside (Mirkazemi, Bereznicki & Peterson,
2013). This is evidenced by her surgical wound dressing that is dry with no ooze.
She may also be dehydrated since she was nil by mouth before surgery and she

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CLINICAL REASONING AND DETERIORATING PATIENT
stated that she only managed sips of water but feels nauseated post-op ( Hooper et
al., 2015)
Internal bleeding (to some extent) is a common complication of a post-op knee
surgery (Mirkazemi, Bereznicki & Peterson, 2013). Internal bleeding may be because of
injury to the vessels in the incision area. If Mary does not get fluids she might go
into serious shock which is a medical emergency requiring immediate intervention
( Hooper et al., 2015). She may also go into an acute confusion state if her pain is
not manage or controlled and hypoxemia that leads to multisystem organ failure if
her oxygen levels are not increased (Mirkazemi, Bereznicki & Peterson, 2013).
Identifying the problem/issue
Decreased fluid volume reduces blood return to the heart resulting in a decline in
preload that leads to a drop in cardiac output ( Maas et al., 2013) Evidenced by
hypotension, capillary refill, pain and tachycardia Mary has reduced cardiac output
related to vasodilation and decreased intravascular volume ( Maas et al, 2013).
Vasodilation occurs naturally in a human body in response to triggers such as low
oxygen levels. It causes the widening of blood vessels, which in turn increases
blood flow and lowers blood pressure ( Maas et al, 2013). Additionally, factors
such as Mary’s age and weight can also negatively affect vasodilation ( Maas et al,
2013).