NUR2203 Acute Care Across the Lifespan A - Written Assessment

This document provides a written assessment for NUR2203 Acute Care Across the Lifespan A. It includes solutions, pathophysiology of hypovolemic shock, complications postoperative, nursing goals, interventions, and more.

NUR2203 Student Name: Student Number:
NUR2203 Acute Care Across the
Lifespan A
ASSESSMENT CRITERIA: Written
Assessment
Student’s Name:
University:
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Table of contents:
Table of contents: 2
Solution 1. 2
Solution 2. 4
Solution 3. 6
Solution 4. 6
References 10
Solution 1.
The pathophysiology of hypovolemic shock in the present case scenario states that it is caused
due to a reduction in intravascular volume due to loss of extracellular fluid or blood. The
decrease in the volume of circulating blood is referred to as hypovolemia. Hypovolemia has the
tendency to reduce the filling pressure as well as the heart rate (HR) to below the normal values
which are required for maintaining perfusion of tissue in the body, the condition is referred to as
shock. The low blood pressure causes neuroendocrine response through the ANS (autonomous
nervous system), which causes the release of hormones such as adrenaline and noradrenaline
inside the circulation and leads to increase in cardiac contraction, HR while promoting
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vasoconstriction. The process is triggered by receptors such as baroreceptors as well as receptors
of vascular stretching under low pressure. It causes stimulation of the renin-angiotensin system,
hence producing angiotensin II, which is a potential vasoconstrictor, while stimulating the
aldosterone secretion hence, promoting the water as well as salt conservation. The increase in
adrenergic activity also contributes towards the organ flows such as brain, myocardium, etc
(Piras, 2017). Due to fall in BP at a relevant low level, the coronary flow of blood also gets
reduced hence decreasing the ability of the heart muscle to contract and further decreasing DC
causing the severe condition of the shock (Suess & Pinsky, 2015). The hypovolemic shock has
its effect on several body systems along with cellular degradation such as low transport of
sodium as well as potassium between the membrane of the cell, low mitochondrial activity,
dysfunctioning of lysosomes, production of hydrolases as well as cell injury. It further affects the
cellular metabolism of nutrients by decreasing the activity of glucose and insulin (McNeer &
Varon, 2013).
The case study of Eleanor suggested that the patients who undergo a right hemicolectomy for a
poorly differentiated adenocarcinoma of the ascending colon might be presented with extreme
loss of fluid as well as electrolytes due to inadequate fluid therapy leading to low range of
hemoglobin 78g/L, Red cell count (RCC) 3.8 × 10 (12)/l, Haematocrit (HCT) 0.36 as observed in
the patient’s pathology. In the initial 24 hours postoperative phase the abnormal heart rate i/e.,
HR 106 and low blood pressure i.e., BP 90/54, were also observed. Surgical complications
postoperative such as ileus and sepsis might further create complication in managing the fluid
and electrolyte. Under such circumstances, the need for systemic fluid might be high while a loss
in the gastrointestinal fluid can be observed. However, the complications which will arise due to
overloading of fluid might be delayed and are unrecognizable within 24 hours of surgery. The
irrational as well as the use of fluid boluses for the management of hypertension and low urine
output as observed i.e., 15-20 ml/hr is the cause of concern and might lead to excessive fluid
balance. The situation of shock might also be due to atrial fibrillation as well as myocardial
infarction (MI) as Eleanor has a past medical history of MI with left coronary artery stenting.
The factors such as hyperlipidaemia which is caused due to an increase in the level of lipids due
to a high level of cholesterol through hypercholesterolemia and hypertension can also contribute
to increasing the risk of stroke. Some other factors contributing to postoperative stroke include,
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old age as Eleanor is 58 years old woman, asthma, smoking (she smokes for about 10 cigarettes a
day and alcohol consumption of about 2 units/day. The practice of restrictive IV therapy and
medications and their effect on vasopressors might raise concerns regarding systemic
hypertension as well as decreased blood flow in the colon. The sedation score of the patient i.e.,
1 depicts the feeling of anxiety or restlessness which might be due to hypertension (Patel,
Panchagnula, Lutz & Bansal, 2012).
The body might compensate for this physiologically with the help of increased sympathetic tone
which will lead to an increase in the heart rate, cardiac contraction as well as vasoconstriction
towards the peripheral end. The initial changes which are observed in the vital signs at the time
of hypovolemic shock consist of an increase in the blood pressure towards the diastolic end
along with narrowing of pulse pressure. Due to the reduction in volume status, there is a drop in
systolic blood pressure as well due to which the delivery of oxygen towards vital organs is not
able to maintain the demand of oxygen as per the requirement. As a result of which, the cells
tend to switch their metabolism from aerobic to anaerobic causing lactic acidosis. However, due
to an increase in sympathetic drive, the flow of blood flow is consequently diverted from
different organs for preserving the flow of blood towards the heart and brain. Such event results
in tissue ischemia and hence leads to worsening of lactic acidosis. Furthermore, the event if not
prevented might leads to worsening the hemodynamic compromise resulting in death (Noel-
Morgan & Muir, 2018).
Solution 2.
In the present case study of Eleanor, the postoperative bleeding which was caused after
hemicolectomy for a poorly differentiated adenocarcinoma of the ascending colon
procedures is found to be a rare complication. The problem and its risk were found to be
dependent on the hemicolectomy surgery which was performed, the identified co-
morbidities of the patient such as hemostatic balance as well as some clotting system.
The abnormal heart rate, as well as low blood pressure (BP 90/54, HR 106 )as observed
in the case within 24 hours, might be the indicative factor behind the complication. Low
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haemoglobin and hematocrit measurements (Haemoglobin (HB) 78g/L, Haematocrit
(HCT) 0.36) might also help in determining the loss of blood (Kirchhoff, Clavien &
Hahnloser, 2010). Another priority problem recognized is hypertension. The elevated
intra-abdominal pressure as observed in the case might cause an adverse effect over
several organ systems. The patient has hypertension as depicted in the low sedation score
i.e., 1 which might be due to elevations in the pressure of peak airway for the patient.
This results in reduced cardiac output which is caused due to additive effects of reduced
venous return as well as increasing afterload. The low blood flow is also the factor behind
the complication of hypertension as the patient is under hypovolemic shock depicting a
loss of blood which might result in visceral ischemia (Hammond & Margolin, 2006).
Furthermore, the third problem is hernia which is identified due to the practice of midline
laparotomy on the patient. As the contraction in the muscles of the abdominal wall causes
retraction in the edges of the wound. Afterwards, due to the avascular nature of the
midline incision, it might cause impairment in the healing of the wound, and then the
fibres which are present in the linea alba, are present continuously with the wall muscle
of abdominal aponeuroses and might cross the midline (Burger, van't Riet & Jeekel,
2002). CAUTI is one of the common problem associated with the use of an indwelling
urinary catheter which is linked with high morbidity, mortality. The urinary drainage
systems are considered as the place of residence for several multidrug-resistant organisms
as well as a source of infection in such patient. The prolonged use of a urinary catheter
might result in the development of CAUTI (Mukhit Kazi, 2015).
Solution 3.
The nursing goal related to blood loss is identified. As a result of the danger of infection
transmission related with homologous blood transfusion, new choices in blood treatment
- the preservationist and individualized utilization of homologous blood and components;
blood substitutes to help oxygen transport (such as changed hemoglobin arrangements),
new pharmacologic methodologies for limiting blood loss such as desmopressin, and
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expanding the body's capacity to release blood such as recombinant erythropoietin must
be considered (Demirci, Zeman, Schmid & Floerchinger, 2017). The nursing goal for
hypertension includes antihypertensive medication treatment with vasodilators or
adrenergic inhibitors is utilized. Vasodilators as often as possible utilized are hydralazine,
sodium nitroprusside, and nitroglycerin. Vasodilators are powerful in BP decrease yet
may cause reflex tachycardia when utilized alone (Clement, 2015). The primary nursing
goal for hernia includes to evaluates the careful injury site and requests that the patient
report pain power level utilizing an approved pain rating scale. Subsequent to giving pain
medicine as endorsed with the tolerant reaction for adequacy. The nursing goal for
CAUTI recognized is to screen unit-explicit CAUTI rates. Screen normal catheter time
period (catheter days). Screen SCIP postoperative catheter expulsion on catheterization
Day 1 or 2. Pattern unit-explicit IUC use (Mukhit Kazi, 2015).
Solution 4.
Nursing intervention Rationale
Assessment of the onset of nausea and vomiting,
presence of blood, overall physiological
assessment if bile, food, as well as odor (Scholz,
2013).
Providing information and knowledge regarding the
emesis as well as defining characteristics.
Assessment of the skin turgor, the membrane of
the mucous, overall weight, void, as well as
changes in behavior.
Providing information and knowledge regarding the
hydration status; consisting of the loss of
extracellular fluid, reduced level of activity, malaise,
loss in weight, low turgor of skin, and concentrated
urine.
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Assessing the vital signs, which includes apical
pulse, heart rate, respiration rate, oxygen
saturation, FiO2, sedation level, BP, etc.
Providing regular monitoring of the overall
cardiovascular response towards dehydration (such
as weakness, thready pulse, low blood pressure,
increased heart rate). Increased level of respiratory
rate might also contribute towards loss of fluid.
Educating the patient regarding the precautionary
measures for the prevention of tissue trauma as
well as disruption of the mechanism of normal
clotting
Informing about the precautionary measures which
tend to reduce the blood loss risk.
Avoiding the rectal suppositories
Such medications might leads to trauma in the lining
of mucous in the rectum.
Limiting the strain with bowel movements
Such medications might leads to trauma to the
mucous membranes which line the rectum.
Educating the patient as well as the family
members regarding any signs and symptoms
which needs to be reported (Moore & Murtaugh,
2001).
Early evaluation as well as treatment of blood loss
might help to decrease the risk for complications
Antidotes should be given if bleeding is
associated with excessive use of anticoagulant.
Protamine sulfate tend to cause a reversal effect of
heparin.
Monitoring the skin necrosis,as well as any type
of skin color
The patient who are going through the anticoagulant
therapy are found to be at high risk of developing
emboli.
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normal saline nasal sprays should be advised for
use
It helps to decrease the drying and cracking of lining
of mucous and hence reducing the risk of blood loss.
Teaching the patient regarding the measures
which helps in the reduction of constipation such
as increased intake of fluid as well as dietary
fiber.
Increased level of fluid intake as well as dietary fiber
might help in softening the fecal mass to cause easier
defecation.
Nurses play a critical activity in the disclosure, checking, and treatment of ailments and in health
progression in the system. Subsequently, health training and reinforcing were the essential
nursing interventions used to propel health in patients with hypertension inside the ICU, which
bases on engaging changes and empowering individuals and systems to improve health. With
respect to hypertension, a segment of the health training focuses that nurses should address
directions for checking circulatory strain, complexities and holding quick to pharmacological and
nonpharmacological medications, for instance, physical exercise, healthy eating standard,
smoking and drinking discontinuance, and weight loss. Moreover, the engaged self-care
approach bolsters direct changes both in the midst of and after the preparation system. Patients
with hypertension anticipate that backing to should hold quick viably to their embraced remedial
everyday practice, and nurses have the principle work in giving relevant information to help the
fortifying of patients with this affliction (Kirchhoff, Clavien and Hahnloser, 2010).
Nursing interventions inside the Assessment of Needs space recognize and separate social, social
and biological practices and are clearly associated with the Planning zone, which expects to
make targets subject to the evaluation of necessities and to perceive frameworks reliant on taking
in got from hypotheses, confirmation, and practice. It justifies referencing the essentialness of
using nursing logical orders in the sorted out organizing of thought, including home thought, to
achieve the targets of the supported treatment. The confirmation of using theoretical frameworks
as an explanation behind prosperity progression organizing. Such procedures were identified
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with positive outcomes in the patients' prosperity conditions. The Health Promotion Model hopes
to survey the practices that lead to prosperity progression using three basic parts: particular traits
and experiences (prior practices, singular factors); the individual's assessments and learning of
the direction the individual needs to achieve (saw benefits, hindrances, self-practicality, social
effects); and charming prosperity headway rehearses (duty to the game plan of movement,
solicitations and tendencies). Organization coordination to support opportunity and cooperation
were huge nursing interventions inside the Implementation zone, a space that searches for
feasible and capable execution, including human and material resource the board, to improve
patients' prosperity. collaborative efforts intend to hoist wellbeing to outfit individuals with
health and information on dealing with inconveniences and issues. It is like manner empowers
correlative guide, in which individuals manage themselves just as other individuals, similarly as
the system and nature (Guedes et al., 2012).
References
Burger, J., van't Riet, M., & Jeekel, J. (2002). Abdominal Incisions: Techniques and
Postoperative Complications. Scandinavian Journal Of Surgery, 91(4), 315-321. doi:
10.1177/145749690209100401
Clement, D. (2015). Control of Hypertension. Hypertension, 65(1), 25-26. doi:
10.1161/hypertensionaha.114.04256
Demirci, C., Zeman, F., Schmid, C., & Floerchinger, B. (2017). Early postoperative blood
pressure and blood loss after cardiac surgery: A retrospective analysis. Intensive And
Critical Care Nursing, 42, 122-126. doi: 10.1016/j.iccn.2017.02.007
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Guedes, N., Moreira, R., Cavalcante, T., Araujo, T., Lopes, M., Ximenes, L., & Vieira, N.
(2012). Intervenções de enfermagem relacionadas à promoção da saúde em
portadores de hipertensão. Acta Paulista De Enfermagem, 25(1), 151-156. doi:
10.1590/s0103-21002012000100026
Hammond, K., & Margolin, D. (2006). Surgical Hemorrhage, Damage Control, and the
Abdominal Compartment Syndrome. Clinics In Colon And Rectal Surgery, 19(4), 188-
194. doi: 10.1055/s-2006-956439
Kirchhoff, P., Clavien, P., & Hahnloser, D. (2010). Complications in colorectal surgery: risk
factors and preventive strategies. Patient Safety In Surgery, 4(1), 5. doi:
10.1186/1754-9493-4-5
Kirchhoff, P., Clavien, P., & Hahnloser, D. (2010). Complications in colorectal surgery: risk
factors and preventive strategies. Patient Safety In Surgery, 4(1), 5. doi:
10.1186/1754-9493-4-5
McNeer, R., & Varon, A. (2013). Pitfalls of Hemodynamic Monitoring in Patients with
Trauma. Anesthesiology Clinics, 31(1), 179-194. doi: 10.1016/j.anclin.2012.11.005
Moore, K., & Murtaugh, R. (2001). Pathophysiologic Characteristics Of Hypovolemic
Shock. Veterinary Clinics Of North America: Small Animal Practice, 31(6), 1115-1128.
doi: 10.1016/s0195-5616(01)50095-9
Mukhit Kazi, M. (2015). Catheter Associated Urinary Tract Infections (CAUTI) and Antibiotic
Sensitivity Pattern from Confirmed Cases of CAUTI in a Tertiary Care Hospital: A
Prospective Study. Clinical Microbiology: Open Access, 04(02). doi: 10.4172/2327-
5073.1000193
Noel-Morgan, J., & Muir, W. (2018). Anesthesia-Associated Relative Hypovolemia:
Mechanisms, Monitoring, and Treatment Considerations. Frontiers In Veterinary
Science, 5. doi: 10.3389/fvets.2018.00053
Patel, S., Panchagnula, U., Lutz, J., & Bansal, S. (2012). Anesthesia and perioperative
management of colorectal surgical patients - specific issues (part 2). Journal Of
Anaesthesiology Clinical Pharmacology, 28(3), 304. doi: 10.4103/0970-9185.98321
Piras, C. (2017). Hypovolemic Shock. International Physical Medicine & Rehabilitation
Journal, 2(3). doi: 10.15406/ipmrj.2017.02.00053
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Scholz, J. (2013). Accurate Assessment of Blood Loss Saves Lives!. Journal Of Obstetric,
Gynecologic & Neonatal Nursing, 42, S17. doi: 10.1111/1552-6909.12070
Suess, E., & Pinsky, M. (2015). Hemodynamic Monitoring for the Evaluation and Treatment
of Shock: What Is the Current State of the Art?. Seminars In Respiratory And Critical
Care Medicine, 36(06), 890-898. doi: 10.1055/s-0035-1564874
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