Nursing Case Study: Darren Roberts and Post-Surgical Hypovolemia

This nursing case study focuses on a 51-year-old male patient, Darren Roberts, who underwent an open cholecystectomy and presents with potential hypovolemia due to fluid deficit and blood loss, evidenced by clinical signs such as pale, cold, and clammy skin, decreased urine output, and altered vital signs. The assignment details the surgical procedure, pre-existing conditions (hypertension, hyperlipidemia, mild depression), and current medications, highlighting the risk factors for hypovolemia. The nursing goal is to achieve a normotensive state with normal vital signs and adequate urine output. The case study outlines nursing interventions, including fluid administration (normal saline, Ringer's lactate), continuous monitoring of vital signs and fluid balance, assessment for bleeding, oxygen administration, and patient positioning. The rationale behind each intervention is explained, emphasizing the restoration of blood volume, tissue perfusion, and oxygenation. The evaluation of interventions involves monitoring the patient's vital signs, urine output, and overall clinical status, demonstrating the effectiveness of the implemented nursing care. The case study references relevant literature to support the discussed concepts and interventions.

Nursing
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The nursing problem discussed is potential for hypovolemia related to fluid deficit and blood
loss from surgery as evidenced by pale, cold and clammy skin, decreased urine output, blood
pressure <90/60and respiratory rate of >20 breaths/minute.
Cholecystectomy is a surgical procedure that involves surgical removal of the gall bladder. It
is usually removed when someone has inflammation (cholecystitis) or even gall bladder stones
(Crozier, Williams, Chan and Thompson 2018). The main function of a gall bladder is to store
bile juice which is important in the digestion of fats. Someone can survive without a gall bladder,
especially when it brings complications but digestion of heavy fats becomes a problem. After
removal of the gall bladder, the patient can experience some problems, especially related to the
surgery (Evan et al. 2020).
Any surgical procedure leads to blood loss minimum of 200 mls. In other cases where the
patient bleeds more blood loss can even amount to one litre of uncontrolled (Thararinsson et al.
2017). This nursing problem is important to Darren as he has undergone surgery which leads to
blood loss. He has also been having episodes of vomiting, which reduces the amount of fluid in
the body to some extent. Too much blood loss can lead to hypovolemia, shock and even death if
not intervened promptly (Rekman et al. 2017). Fluid loss can also cause electrolyte imbalance.
There should be a balance between body fluids and electrolytes for the body to work properly.
Decreased fluid volume can cause electrolyte levels to be elevated, for example, hyperkalemia
causing cardiac arrest. Electrolytes can also be low, causing fatal consequences.
Advance in age is also a risk factor of hypovolemia after surgery. When someone advances
in age, there is a restricted ability of fluid intake. Polypharmacy and declined mental status are
also a contributing factor during old age (Mahottige, Lehrich and Greenberg 2019). Darren is 51
years old, and he has been previously managed for hypertension, hyperlipidemia, mild

depression and gastric esophageal reflux. He has been taking drugs for this condition before
current admission (Chung, Bateson and Patel 2018). Hemostasis is also delayed as one advance
in age as the body hemodynamics changes which can predispose someone to lose more blood.
Co-existing conditions such as hypertension can also be a risk factor for losing more blood.
After surgery, especially abdominal surgery, the patient has delayed oral intake (Hackert et
al. 2018). This can greatly increase the risk of hypovolemia in Darren's case. It is therefore
important to anticipate the risk of occurrence of a problem before it happens and appropriate
interventions put into practice. This will help prevent organ damage, preserve organ function and
prevent shock occurrence. This can be easily detected by monitoring the patient's vital signs. Any
decrease in blood pressure or blood pressure below 90/60 mmHg is an alarm. Changes in skin
color from pink to pale, cold extremities, increase in capillary refill time are all signs of
hypovolemia as there is decreased blood flow to the extremities. Breathing also becomes fast as
the body tries to compensate by increasing the amount of oxygen intake as with hypovolemia,
there is decreased oxygen amount in the tissues.
Nursing goal
The patient should attain a normotensive state that is vital signs within the normal range
(blood pressure 12-/80-140/90 mmHg, RR 12-16 bpm, normal pink skin colour, warm skin and
extremities within two hours. Urine output should also increase to approximately 250 mls every
3 hours.
Nursing interventions and rationale
The first nursing intervention in the risk of hypovolemia is the administration of fluids or
volume expanders. The most commonly used fluids are normal saline and ringers lactate.
Amount of fluid administered and frequency depends on the severity of hypovolemia and the

general state of the patient. Very low blood pressure will require a fast flow of fluid to restore the
volume quickly (Montomoli, Donati and Ince 2019).
The main rationale of fluid administration is to increase blood volume. Increase in blood
volume increases arterial blood pressure and in turn, venous blood pressure. This increases
preload increases stroke volume and finally increase in cardiac output. Increase in cardiac output
increases blood flow to body organs and tissues. Increased tissue perfusion increases tissue
oxygenation and thus restores normal organ function, especially vital organs such as the brain
and the heart (Thagavi and Askari 2019). This brings the body to a normal state as blood
pressure increases, respiratory rate decrease and normal skin color is restored as there is adequate
blood flow to the skin and extremities. Urine output also increases as enough blood reaches the
kidney and waste products can be filtered effectively (Egal, 2018).
Other solutions that can be used include plasma proteins and other plasma expanders and
even blood transfusion if blood loss is so extreme. The patient can also be given fluids orally as
soon as it is tolerated. The patient can take as many fluids as possible. This is more advantageous
as there is no risk of cardiovascular overload, and it helps in recovery as the body gains
hemodynamics as soon as possible. During fluid administration, the nurse should continuously
monitor the patient for any changes and abnormal findings, especially when the patient is not
alert. A fluid chart should be used to monitor input and output and vital signs taken after every
15 minutes to detect ant abnormalities and proper interventions put in place. The nurse should
observe for signs of fluid overload such as difficulty in breathing, pulmonary edema and
distension of jugular vein (Taghavi and Askari 2019).
Another nursing intervention is to monitor the patient for any cause of hypovolemia. The
patient might be bleeding from the side of the surgical incision. The bleeding can be either

external, which can be seen easily, or it can be internal. Continuous bleeding of any amount can
be fatal to the patient. If the bleeding is external, an attempt to stop the bleeding should be made
like covering the site with sterile gauze as the physician is informed for immediate intervention
(Kim et al. 2019). The physician should also be informed as soon as possible if internal bleeding
is suspected. Signs of internal bleeding include a continued drop in blood pressure even with
administration of fluids. The patient remains unconscious, and the skin remains pale and cold.
Heart rate increases become fast, and ponding and the respiratory rate remains high.
Occasionally the abdomen may become distended after some time. To stop the bleeding, this
will require that the site of incision be reopened and the bleeding stopped. The patient should
also be nursed in a Trendelenburg position to promote blood flow to the brain and other vital
organs. It also promotes venous return and blood flow to the lungs. It is the main position used to
manage shock.
Another nursing intervention is oxygen administration. With decreased fluid or blood
volume, there is decreased oxygen supply to the tissues, and thus the patient had to breathe faster
and shallow. The patient, therefore, uses much energy in breathing which should have been
otherwise spontaneous. The patient might even have signs of respiratory distress such as the use
of accessory muscles, nasal flaring and chest in the drawing. Oxygen administration via an
oxygen mask or nasal prongs increases the amount of oxygen delivered to the lungs and
subsequently to the blood (Schiffner et al. 2020). Therefore enough oxygen reaches body tissues
and organs, promoting normal metabolism and proper organ functioning. The level of carbon
(IV) oxide in the blood also decreases and therefore, feedback is sent to the respiratory centre in
the brain to reduce the respiratory rate to normal. Respiratory rate eventually normalized and

laboured breathing is stopped. This promotes recovery, especially when the patient was out from
surgery (Suh et al. 2018).
Evaluation of nursing interventions
Fluid administration is monitored using the input/output fluid chart. This helps the nurse to
know the amount of fluid taken by the patient and amount eliminated through urine, vomiting
and insensible loss through sweating and respiration. There should be a balance, but the output
should never be higher than the input. The normal response is that there should be an increase in
blood pressure gradually to normal. Blood pressure measured every 15 minutes should show an
improvement. Also, other vitals such as heart rate and respiratory rate should normalize. After
two hours, Darren's blood pressure was 124/82 mmHg, heart rate of 78 bpm and respiratory rate
of 16 breaths per minute. There was an increase in urine output also. This shows that the
intervention was effective (Gholami et al. 2018).
In the evaluation of bleeding, there were no signs of a drop in blood pressure, increase in
heart rate or respiratory rate. Instead, there was an improvement in parameters. The patient's
level of consciousness also improved. The patient remained nursed in a Trendelenburg position
with no signs of external bleeding or abdominal distension (Wilkins et al. 2020).
Finally, evaluation of oxygen therapy, after two hours, Darren’s respiratory rate was 16
breaths per minute; the patient was calm and no evidence of laboured breathing. The skin had
normalized to pink. This shows that the intervention was effective (Soedjono et al. 2019).

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