Nursing Priorities for Eleanor Wilson's Care

This document discusses the nursing priorities for the care of Eleanor Wilson, a patient experiencing post-operative hypovolemia. The nursing priorities identified include deficient fluid volume, decreased cardiac output, ineffective tissue perfusion, and risk for infection. The document also provides goals and interventions for each nursing problem.

Question 1
Eleanor Wilson is a 58year old woman. Social history shows that she is married and has two kids
and has been working in administration for 20 hours in a week, and she is smoking 20 cigarettes
and drinks 2 units of alcohol every day. She has never been involved in a nation bowel screening
program or colonoscopy. She has been admitted to hospital due to her recent reports on the
change of bowel habits and her GP has made possible for blood testing and colonoscopy. On her
past medical history, she has had hypercholesterolemia, lap cholecystectomy, asthma, and
myocardial infarction with left coronary artery. Eleanor has a family history of cancer, the father
had bowel cancer while the mother also died of pancreatic cancer. On her current illness, she has
been feeling very tired and she presented to her GP history of constipation, blood in her stools
and general malaise which has occurred for the past three months. She is currently under the
following drugs: Simvastatin 40mg, captopril 50mg, ranitidine 150mg, and Aspirin 75mg mane.
On laboratory test her carcinogen antigen has increased, hematocrit decreased and her
hemoglobin level is low compared to normal range and her gender, her heart rate is high and also
BMI of 28.4 which indicate pre-obesity.
Hypovolemia is a condition which causes the body to have decreased blood volume especially
blood plasma (Goswami, et al, 2018). It has the following symptom: sodium depletion, excessive
loss of body water and dehydration. Trauma is one cause among the many causes of
hypovolemia as it may cause excessive blood loss which eventually causes dehydration
(Pachtinger, 2014). In this case, Eleanor underwent acute surgery for resection of tumor which
led to decreased amount of blood circulating which in turn lowered cardiac refill and venous
return hence causing hypotension in the arteries. Reduced circulating volume leads to decrease
tissue perfusion which can result to excess oxygen demand which leads to myocardial infarction.
Reduced tissue perfusion also cause an anaerobic embolism, this is metabolism in the absence of
oxygen resulting in acidosis, it can cause multi-organ failure. At some point during
intraoperative management fluid volume can be managed inappropriately by estimating it
incorrectly and this leads to poor management of patient's fluid volume which contributes to
hypovolemia. Eleanor has a blood pressure of systolic 90 and diastolic of 54, this is lower than
the normal range of 100-120 for systolic and diastolic pressure (Ferreira et.al, 2015) respectively
this is a clear sign of hypovolemia indicated by hypotension. The patient has a Hematocrit level

of 0.36 compared to the normal range of 0.37-0.47. She has tachycardia with an increased heart
to 106 compared to the normal heart rate of 60-100 beats per minute. She has a low urine output
of 15-20mls/hour which is lower than normal of more than 30mls/hour. This objectively obtained
data clearly shows signs of hypovolemia in our patients which is a danger sign as it needs proper
management of signs and symptoms.
Eleanor's body will be able to compensate for reduced circulating blood in many ways, the
following are ways in which the body can compensate physiologically: Baroreceptor reflexes
sense fall in central venous blood pressure through arterial and cardiopulmonary baroreceptors
(Wehrwein, & Joyner, 2013), chemoreceptor reflexes which increases sympathetic activity
which stimulates heart and its vessels to increase arterial pressure, vasoconstriction of vessels,
renal angiotensin aldosterone system in the kidney which enables reabsorption of water and
sodium, causes vasoconstriction and enhanced sympathetic activity , activation of thirst
mechanism in the brain and reabsorption of tissue fluids. If bleeding is stopped, arterial pressure
goes back to normal and heart rate is decreased and long term compensatory mechanisms are
activated which restores back the normal arterial pressure and blood volume back to normal.
During bleed, the kidneys compensate by increasing Renin which causes vasoconstriction
(Gomez et., 2018) The aim of this compensatory mechanism is to increase cardiac output and
arterial pressure. Some neurotransmitters such as catecholamine and specifically epinephrine,
dopamine, and norepinephrine activate sympathetic adrenergic system which helps in regulating
physiological functions leading to heart stimulations thus increasing heart rate and contractility
force. Vasoconstriction of vessels increases systemic vascular resistance. Cardiac output is, in
turn, redistributed from less important organs to organs which are critical for survival such as the
brain. The body causes reduced capillary pressure which leads to reduced fluids leaving the
capillaries and when excessive hemorrhage occurs and it falls, reabsorption of fluid can later
occur from tissue interstitial back to blood plasma increasing blood volume.
Question 2
The various data that have been obtained in the assessment of Eleanor Wilson can be used to
identify the nursing priorities for her care. These findings include; the respiratory rate of 12
breaths per min, blood pressure of 90/54 mm Hg, pulse of 106 beats per min, the temperature of

36.9 C and a sedation score of 1. She also has hourly urine of 15 – 20 ml/hr. Eleanor is⁰
experiencing post-operative hypovolemia and there his care should be prioritized towards
handling this condition. The aim of the nursing care has to be aimed at addressing the cause of
shock and also making sure that the intravascular volume has been reduced. Following the
assessment data in the case study, four nursing priorities of care that are identified include;
deficient fluid volume, decreased cardiac output, ineffective tissue perfusion and risk for
infection.
Deficient fluid volume is related to active fluid volume loss as evidenced by increased heart rate
(tachycardia) and low urine output (15-20 ml/hr). There is a decrease in the patient’s body fluid
which is because of the fluid loss experienced during the resection of the tumor. The patient also
lost blood following right hemicolectomy. It is therefore important to restore the patient fluid
volume to prevent hypovolemic shock (Chatrath, Khetarpal, & Ahuja, 2015).
Decreased cardiac output related fluid volume loss as evidenced by decreased blood pressure,
decreased urinary output and tachycardia. This is another nursing problem that has to be
prioritized because the decrease in cardiac output may result in decreased tissue perfusion which
further leads to an increase in myocardial oxygen demand that can cause myocardial infarction.
She has a urine output of 15-20mls per hour which is less than the normal range of ≥30mls per
hour.
The third nursing problem identified for Eleanor case is ineffective tissue perfusion related to
severe blood loss and diminished venous return as evidenced shallow respirations. This the
`reduce in oxygen supply in the body such that it is inadequate to nourish the tissues at the
capillary level.
The fourth nursing problem is the increased risk of infection. Eleanor has undergone surgery and
therefore has a wound which is at risk of getting infected if not well cared for, especially due to
the exposure to the hospital environment which has a lot of pathogens. Moreover, she has an
indwelling catheter which can be another source of infection if proper catheter care is not
provided.
Question 3

Each of the nursing problem identified has a goal which defines the expected outcome for the
patient care. The nursing goal for the care of deficient fluid volume is that Eleanor will be
normovolemic with systolic greater or equal to 90 mm Hg, normal skin turgor and urinary output
of 30ml/hr. The expected outcome for decreased cardiac output is that the client will achieve an
adequate cardiac output which is characterized by a heart rate of 60-100 beats with regular
rhythm and urinary of 30 ml/hr. For ineffective tissue perfusion, the nursing goal is that the client
will maintain tissue perfusion that is maximum as seen by warm and dry skin, available and
strong peripheral pulses, lack of chest pain, normal vitals and absence of edema. The goal for
increased risk for infection is to ensure that Eleanor remains free of infection which will be
justified by normal vital signs and absence of purulent drainage from the wound, incision, and
catheter. Infection should also be recognized early and prompt treatment initiated.
Question 4
From the four nursing goals identified, I will discuss the interventions and their rationale for the
goal of Decreased cardiac output and increased risk of infection.
For decreased cardiac output, Eleanor will achieve an adequate cardiac output which is
characterized by a heart rate of 60-100 beats per minute with regular rhythm and urinary output
of 30mls/hour or more. To achieve this the nurse should therefore assess clients heart rate and
blood pressure every 4 hours. The rationale of doing this is that increase arterial blood pressure
and tachycardia is seen in early stages. For the body to maintain an adequate output, hypotension
occurs as the client’s condition worsen and vasoconstriction may cause unreliable blood pressure
and pulse pressure decreases in shock that's why it need close monitoring for early detection and
treatment. Nurse should asses the clients ECG the rationale of this is to prevent the occurrence of
cardiac dysrhythmias as they occur due to low perfusions state, acidosis and hypoxia and also
cardiac drugs such as captopril which contribute to cardiac dysrhythmias, restlessness and
anxiety are early signs of hypoxia while loss of consciousness and confusion occurs at a later
stage thus it needs close monitoring. Asses' central and peripheral pulses this is because pulses
are weak with reduced stroke volume and cardiac output (Yang, & Du, 2014). Asses capillary
refill time the rationale of this that capillary refill is slow and sometimes absent during
hypovolemic thus it needs close monitoring. Asses respiratory rate rhythm and auscultate breath

sounds so that danger signs such as wheezes and crackles can be identified as early as possible,
shallow respirations will also be identified and be monitored. Nurse to monitor oxygen saturation
and arterial blood gases using pulse oximetry, the rationale of this is to monitor oxygen which
should be at 90% or higher as hypovolemia declines aerobic metabolism resulting to increased
carbon dioxide and decreasing PH. Nurse should be able to monitor patients central venous
pressure and pulmonary artery diastolic pressure (Adam, Osborne, & Welch, 2017), the rationale
of this is that central venous pressure is able to provide information on the filling pressures of the
right side of the heart while pulmonary artery diastolic pressure is able to provide information on
left-side fluid volumes. Asses urine output the rationale is that urine output less than 400mls/day
is a classic sign of reduced cardiac output hence it needs to be closely monitored. Asses skin
temperature, color, and moisture. Cool, pale and clammy skin in the sympathetic nervous system
stimulation and low cardiac output is a secondary compensatory increase. Administer fluid and
blood replacement this is to maintain adequate circulation.
The goal of Increased risk of infection aim at ensuring that the patient remains free of infection
(Loveday, et.al, 2013) and any signs of infections are identified early enough. This will ensure
that any infection that may occur is handled effectively with prompt treatment before
complications arise. The nursing interventions for this problem and their rationale include the
following;
The nurse should assess Mrs. Eleanor for the presence of wounds and abrasions and also
indwelling catheter. The nurse should not just assume that the surgical wounds and incision are
the only wounds available but assess her to find out if there are any other wounds available. This
is because presences of wounds and abrasions or indwelling catheter represent a break in the first
line of the body defenses (McCrossan, 2013). Therefore, the patient may easily get an infection.
The nurse should also monitor the white blood count. When white blood cell count rises it
indicates the body's effort to combat pathogen hence an indication of infection.
Monitoring for the signs of infection is also another intervention for this problem. These signs of
infection include redness, increased pain, swelling and presence or pus (Harrington, 2014). An
elevated temperature may also be a sign of infection. When such signs are noted, prompt actions
should be initiated to prevent complications from arising. Moreover, the patient's nutritional

status should be assessed (Fontes, et.al, 2014). If the patient has poor nutritional status, then the
immune response may be low hence the further risk of infection.
The nurse has to also maintain asepsis during wound care procedures and also for catheter care
(Dougherty, & Lister, 2015). He or she should teach the patient and other caregivers on proper
hand washing techniques and even limit the number of visitors that come to visit the patient. This
will reduce greatly the introduction of pathogens into the patient environment and even body.
The nurse also has the role of teaching relatives who come visiting about proper techniques for
preventing infections (Bastable, 2017). This includes proper hand washing and also ensuring that
the food and fruits that they bring to the patient are free from pathogens. The nurse should
encourage the patient to make use of toothbrushes that are soft-bristled and stool softeners to
protect mucous membranes. Damaged mucous membranes will be a source of infection and
that’s why they should be protected. Lastly, the patient can be isolated to give proper risk
protection from pathogens. When the patient is isolated there less exposure to the pathogens and
hence reducing the risk of infection.

References
Adam, S., Osborne, S., & Welch, J. (Eds.). (2017). Critical care nursing: science and practice.
Oxford University Press.
Bastable, S. B. (2017). Nurse as educator: Principles of teaching and learning for nursing
practice. Jones & Bartlett Learning.
Chatrath, V., Khetarpal, R., & Ahuja, J. (2015). Fluid management in patients with trauma:
Restrictive versus liberal approach. Journal of anaesthesiology, clinical
pharmacology, 31(3), 308.
Dougherty, L., & Lister, S. (Eds.). (2015). The Royal Marsden manual of clinical nursing
procedures. John Wiley & Sons.
Ferreira, V. M., Wijesurendra, R. S., Liu, A., Greiser, A., Casadei, B., Robson, M. D., ... &
Piechnik, S. K. (2015). Systolic ShMOLLI myocardial T1-mapping for improved
robustness to partial-volume effects and applications in tachyarrhythmias. Journal of
Cardiovascular Magnetic Resonance, 17(1), 77.
Fontes, D., de Vasconcelos Generoso, S., & Correia, M. I. T. D. (2014). Subjective global
assessment: a reliable nutritional assessment tool to predict outcomes in critically ill
patients. Clinical nutrition, 33(2), 291-295.
Gomez, R. A., & Sequeira-Lopez, M. L. S. (2018). Renin cells in homeostasis, regeneration and
immune defence mechanisms. Nature Reviews Nephrology, 14(4), 231.
Goswami, N., Blaber, A. P., Hinghofer-Szalkay, H., & Convertino, V. A. (2018). Lower body
negative pressure: physiological effects, applications, and implementation. Physiological
reviews, 99(1), 807-851.
Harrington, P. (2014). Prevention of surgical site infection. Nursing standard, 28(48).

Loveday, H. P., Wilson, J., Pratt, R. J., Golsorkhi, M., Tingle, A., Bak, A., ... & Wilcox, M.
(2014). epic3: national evidence-based guidelines for preventing healthcare-associated
infections in NHS hospitals in England. Journal of Hospital Infection, 86, S1-S70.
McCrossan, G. L. (2013). Preventing the spread of infection. Foundations of Nursing Practice
E-Book: Fundamentals of Holistic Care, 337.
Pachtinger, G. E. (2014). Hypovolemic shock. Clinician’s Brief, 13-16.
Wehrwein, E. A., & Joyner, M. J. (2013). Regulation of blood pressure by the arterial baroreflex
and autonomic nervous system. In Handbook of clinical neurology (Vol. 117, pp. 89-
102). Elsevier.
Yang, X., & Du, B. (2014). Does pulse pressure variation predict fluid responsiveness in
critically ill patients? A systematic review and meta-analysis. Critical care, 18(6), 650.