Nursing Patients with Acute Illness

This article discusses nursing patients with acute illness, focusing on the importance of potential hypovolemia and the nursing interventions to address it. It also explores evidence-based assessments used to evaluate the effectiveness of these interventions.

Running head: NURSING PATIENTS WITH ACUTE ILLNESS 1
Nursing patients with acute illness
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NURSING PATIENTS WITH ACUTE ILLNESS 2
Nursing patients with acute illness
Patient data
In the case study, Darren is a patient who barely 4 hours from surgery. On assessment,
there is potential for hypovolemia due to fluid deficit and excessive blood loss from the surgical
procedure. This was evidenced by the following data: Pale, cold and clammy skin, decreased
urine output, Blood pressure greater than 90/60 and a respiratory rate greater than 20 rpm
The importance of potential for hypovolemia related to fluid deficit and blood loss
from surgical procedure
Whenever there is excessive loss of blood and other body fluids in the body, the volume
of blood circulating in the body drops considerably as well. Hypovolemia then happens
suddenly. Therefore, hypovolemia can be defined as a condition in which there is low blood
volume in the body due to excessive loss of blood or body fluids.
In this case study involving Darren, this condition is important since it’s considered a life
threatening emergency. Blood plays different roles in the body such as maintaining body
temperature, forming blood clots to prevent further loss of blood and finally moves or transports
oxygen and other nutrients to cells of the body so that they can carry out their normal functions
(Vincent, 2019). If the volume of blood drops as a result of bleeding like in the case of Darren,
then the organs wont function properly and this is why this condition is of nursing importance.
There are different causes of hypovolemia such as bursting of blood vessels and serious
injuries. In this case however, the major cause of the condition is excessive bleeding after a
major surgery. There are different signs and symptoms for hypovolemia and they include fatigue,
nausea, low blood pressure and dizziness (Van der Jagt, 2016). Others include cool and clammy

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skin, rapid heartbeat and quick and shallow breathing. In the case of Darren, the data obtained
pointed to hypovolemia due to the low pressure(less than 90/60. Other features that pointed out
to hypovolemia include decreased urine output, cold and clammy skin and a respiratory rate that
was below 20Rpm.
Another mechanism that explain the importance of potential hypovolemia is through the
pathophysiology of the condition. During hypovolemia, low fluid volume lowers the amount of
blood that returns to the heart and this leads to decline in preload. As preload lowers, the cardiac
output also drops. In order to make up for the low cardiac output, the heart rate speeds up while
the vascular resistance increases. Later, cardiac output Improves as the tissue perfusion pressure
increase. This in return trigger the release of catecholamine (Schindler & Marx, 2016). The
volume of blood increases as the interstitial fluid shifts towards the intravascular spaces. The
liver and spleen then released stored red blood cells. This system collectively stimulate renin-
angiotensin-aldosterone system that promote retention of water and sodium as the body attempt
to raise the systolic pressure. The volume of urine then drops (Woodcock & Woodcock, 2012). If
the situation persists, the system down supply of blood to organs that causes damage of organs in
catabolic state. Cellular death then follows. It is therefore necessary to come up with nursing
interventions as soon as possible to curb the condition.
Patient centered SMART Goal for Darren’s Nursing problem
The SMART goal for Darren’s Nursing problem is that he is restored back to
normovolemic state. This can be indicated by a systolic blood pressure of more than 90 mm Hg,
absence of orthostatic and urine output of more than 40ml/hr.

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Three nursing intervention
Administration of blood products is another nursing intervention in the case of
hypovolemia. As previously explained, hypovolemia is due to the excessive loss of blood and
body fluids due to surgery like in the case of Darren. The aim or rather the rationale of this
nursing intervention is to restore the normal quantity of blood to the body so that the heart is able
to pump blood to different cells so that organs can function normally.
During this nursing intervention, the nurse has to carry out a blood test to ascertain the
blood group of the patient. After that, the nurse submits a request for the same blood products to
relevant physicians. Different cross match tests are done. The aim of the cross match is to
establish if the blood of the donor and the recipient are compatible. This is to prevent transfusion
reactions such as agglutination. Agglutination can cause death to the patient. The nurse is also
supposed to cross check the blood with another nurse. All these protocols are just to reduce the
risk of human errors. The protocol for infusion is as follows: q15min x 2, q30 min x 1, and q1h
(Merchant & Davies, 2015). However, rapid infusion is sometimes recommended. Since packed
red blood cells do not have clotting factors, platelets and plasma, it is necessary to give them at
certain intervals during rapid infusion so as to prevent the clotting problems. The nurse is
supposed to adhere to the protocol so that eventually, the patient (Darren) feels better.
The second nursing intervention is oxygen therapy. In the case study, dizziness was
reported by Darren. Dizziness is as a result of low oxygen to the brain. Therefore, the rationale of
this nursing intervention is to supply extra oxygen so that not only the brain but other organs
operate normally. During oxygen therapy, oxygen from an artificial source is delivered through
the gas masks or cannula (Perner, Laake, & Van der Horst, 2018). Oxygen can either be
delivered in form of gas or liquid. Before oxygen is provided, the nurse ought to assess the level

NURSING PATIENTS WITH ACUTE ILLNESS 5
of oxygen so as to determine the quantity to be provided. This is mostly done by a blood test or a
pulse oximeter which is either placed on the ear lobe or toe.
Once the level of oxygen in the body has been determined, the nurse can then prescribe
the quantity and the time the oxygen is to be delivered to the patient. This is the most critical
stage and the nurse ought to be very careful on the quantity since studies indicate that high or
low levels of oxygen are both detrimental. High oxygen slows down the rate of breathing while
low oxygen can severely damage the brain.
Monitoring vital signs like blood pressure, weight and pulse rate in orthostatic changes is
the final nursing intervention. The goal of this nursing intervention is that to ensure the vital
signs are within the normal ranges (Manning, Dunkman, & Miller, 2017). According to recent
studies, one of the indicators of fluid loss is postural hypotension. The nurse should therefore
monitor any changes. Some of the notable changes include hypotension. A change greater than
10 mm Hg for example signifies more than 20% decrease in the blood volume while between 20
to 30 mm Hg signifies that circulating blood has dropped by 40% (Heifets, Tanaka, & Burbridge,
2018). The nurse should also monitor the weight of the patient. He should be weighed on a daily
basis at the same time with the same clothes so as to identify any variations. A consistent drop in
weight signifies loss of fluids and blood and calls for sudden nursing interventions. Nurses
should adhere to the protocols of nursing interventions so as to prevent further complications as a
result of hypovolemia.
Evidence based assessments used to evaluate the effectiveness of implemented
nursing intervention.

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To effectively evaluate the effectiveness of the different nursing interventions
implemented, different evidence based assessments will be conducted. The first assessment of
color and the quantity of urine. According to recent studies, the color and quantity of urine can
be used to evaluate the effectiveness of administration of fluids. A normal urine output should
not be less than 30ml/hr (Filyk, 2016). A concentrated urine on the other hand denotes fluid
deficit. Therefore, if in this case the urine output per hour is more than 30ml and it’s diluted, it
means that the nursing intervention was successful. If otherwise, it means it was not effective
and there is the need to get back to the drawing board.
Auscultation and documentation of heart sounds, rate and rhythm can be used to evaluate
the effectiveness of the nursing interventions. Studies indicate that cardiac alterations such as
dysrhythmias indicate hypovolemia (Eldawlatly, 2017). In order to establish if the nursing
intervention was effective therefore, it is vital to check out for the above parameters of which
absence denotes the effectiveness of the interventions while presence indicates that the
interventions failed.
Assessment of weight can play a critical role in evaluating the effectiveness of nursing
interventions as well. According to research, a week increased in lb. by 2 is an indicator for
normal status. In fact, weight is considered to be the best assessment data for fluid imbalance and
potential hypovolemia. In this case therefore, if there will be a 2lbs increase in a week, it will
denote or indicate the effectiveness of the nursing interventions (Damani & Suarez, 2018).
Contrary results on the other hand will indicate the ineffectiveness of the nursing interventions.
Another crucial evidence based assessment for the effectiveness of the nursing interventions is
skin turgor and the oral mucous membranes. Studies document that it is possible to detect
dehydration through the skin. After the nursing interventions, it is expected that signs of

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dehydration such as inelastic skin and longitudinal furrows on the tongue should disappear. This
will indicate the effectiveness of the interventions. If the above signs still persist, then that means
that the nursing interventions were unsuccessful (Bryson, 2014). Evaluation of any nursing
intervention is using evidence based techniques is necessary. This is because it indicates if the
intervention is working or not. In case it is working, then the nurse should continue with the
same. However, if there is no signs of improvement, then the nurse ought to get back to the
drawing board and come up with better nursing interventions.

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References
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