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Question 1: Pathophysiology of Mr. Jensen’s post-operative hypovolemia
Hypovolemia is a surgical condition that indicates the rapid fluid loss that may result in organ failures. The outcomes of the hypovolemia are mostly due to insufficient circulating volume or scarce perfusion. Often hypovolemia is secondary to hemorrhage the reason of which includes severe internal or external blood loss and GI, thoracic and abdominal bleeding maladies (Devitt, 2001).
Hypovolemia involves significant fluid loss other than blood that can be further accompanied by refractory gastroenteritis and widespread burns. Hypovolemia may develop in post-surgical incidence, bone fracture, due to fluid loss and any underlying chronic condition like diabetes. It may develop as stress response and high BGL in relation to osmotic diuresis through causing water loss by the kidney (Hypovolemic Shock: Background, Pathophysiology, 2016).
The body fluid loss can also reduce the volume of blood that carries oxygen to the organs. The severity of fluid loss defines the level of hypovolemia. It is a life-threatening surgical condition that requires urgent medical intervention. Mild symptoms of hypovolemia include a headache, fatigue, dizziness, nausea, and sweating. The severe symptoms of hypovolemia include cold and pale skin, fast breathing and palpitation with a weak pulse. The hemorrhagic condition is prominent if it is external. In the case of an internal hemorrhagic condition, the symptoms include blood in urine and in vomiting which can be accompanied by abdominal swelling and pain. The human body responds to such condition by stimulating the other physiological conditions of the body that involve renal, cardiovascular, neuroendocrine and hematologic systems (Hypovolemic Shock: Background, Pathophysiology, 2016).
The hematologic systems activate the series of coagulation and contract the oozing vessels to respond to any severe blood loss. Moreover, the platelets are activated to create a clot on these tissues. The haematologic system acts in a very accurate way, and the impacted vessels start producing collagen that results in fibrin accumulation and stabilizes the clot.
The cardiovascular system first increases the heart rate and increase the myocardial compression along with reducing the diameter of peripheral blood vessels. The response of cardiovascular system against hypovolemia includes the elevation of norepinephrine and reduction in baseline vagal tone. The renal system increases the urine secretion to balance the occurred surgical condition. The renal secreted by juxtaglomerular apparatus transforms the angiotensinogen into angiotansin-1. Later on, angiotensin-1 is turned into angiotansin-2 which acts in two ways, firstly it inverses the hemorrhagic shock, and facilitates the vasoconstriction of arteriolar muscles. Secondly, it triggers the release of aldosterone that mainly contributes to sodium reabsorption as well as water conservation and fluid retention (Hypovolemic Shock: Background, Pathophysiology, 2016).
The neuroendocrine system responds against hypovolemic condition through increase the level of circulating antidiuretic hormone. In such condition, the posterior pituitary gland is stimulated to secrete the high level of the antidiuretic hormone when the reduction is sensed in blood pressure (via baroreceptors in carotid and aortic arch) and sodium concentration (via osmoreceptors). The antidiuretic hormone also results in elevated reabsorption of salt and water through collecting ducts, distal tubule, and the loop of Henle. Blood and fluid loss results in reduced blood volume and blood pressure which phenomenon is also termed as Baroreceptor reflex which is identified by baroreceptors that stimulate the sympathetic nerves that start releasing norepinephrine and subsequently epinephrine. It restricts the diameter of peripheral blood vessels located under the skin and increases heart contraction and heart rate. Moreover, kidney, brain, and heart arteries are capable of autoregulation which helps them to maintain the sufficient blood perfusion even with lowered blood pressure (systolic BP 60-100 mm Hg) (Bratton et al., 2007). This mechanism redirects the blood flow from muscle, skin, and GI tract towards kidney, brain, and heart. For fluid retention, the Atrial volume receptors in the body trigger the antidiuretic hormone, the water excretion from kidneys is lowered. Osmoreceptors in the hypothalamus sense the increased blood osmolarity and stimulates ADH (Hypovolemic Shock: Background, Pathophysiology, 2016; Bratton et al., 2007).
Moreover, in the case of any injury or surgery when the body tries to heal the wound the liver is stimulated to produce extra sugar. But in the case of the diabetic patient this extra sugar cannot be consumed by the body. High BGL of the patient sugar can also impact with the recovery pace of the surgical wound and may lead to cerebral diabetic ketoacidosis, a life-threatening condition of fluid loss due to hyperglycemia (Strunden et al., 2011).
The pathophysiology of hypovolemia is extensively multifaceted, and the response of various physiologic systems in the body targets to maintain the vital organ perfusion in the case of severe blood loss. In the absence of critical management of this condition and proper blood and fluid resuscitation, it may cause cardiac perfusion, hemorrhage and finally multiple organ failures (Strunden et al., 2011).
Question2: PRIORITY problems and justification
The priority problems of Mr. Jensen include:
• Pain (Score 7 on a scale of 1-10): Pain is the priority problem. Pain is mediated by nociceptive somatic nerve fibers. Pain is a clinical problem because it may lead to increased heart rate, myocardial contraction, myocardial strain and increased oxygen demand, urinary retention and detrimental impacts on recovery (Leaper, Whitaker & Leaper, 2010).
• Fluid loss or deficit: Fluid loss is the second problem of the patient that is caused by multiple factors such as high BGL, fracture, and surgery. If not controlled timely it can result in numerous complexities with a high risk of hypovolemia and multiple organ failures.
• Poor circulation (right leg is cool to touch): The poor circulation indicates the loss of blood volume and indicates the risk of hypovolemia.
• Increased blood glucose level of 17mmols/ltr: Hypovolemia also might be contributed by the underlying chronic condition of diabetes or high BGL because it damages water volume in the body and leads to cerebral diabetic ketoacidosis, a life-threatening condition (Piva, Garcia & Lago, 2012).
• Breathing problem (increased Respiratory rate 24BPM): Increased rapid rate of the heart is the reason for hypovolemia, and the irregular respiratory rate is an interpreter of severe clinical events that determines the stability rate of the patient. In this case, the patient is critically ill. Any condition that can disturb the internal body environment like sepsis may be a reason for increased respiratory rate, and it may result in elevated CO2 production (Maddox et al., 2008; Cretikos et al., 2008). • Hypotension: Hypotension is related to increased cardiac and renal complexities after surgery. Patients with cardiac disease and diabetes have a negative fluid balance that can further exacerbate the complications (Kheterpal et al., 2007; Bijker et al., 2009).
• Elevated temperature 37.9°C: Elevated temperature increases the risks of infections. Blood coagulation and blood platelet functioning is an enzyme and temperature-dependent mechanism that is impacted by high body temperature. Thus other risks include bleeding, deferred wound healing, lowered supply of oxygen to body tissues, and reduced metabolism (Gögenur et al., 2007).
• Low SaO2 95%, despite 6liters of oxygen via Hudson mask: SaO2 estimates oxygen saturation level in the heme groups inside hemoglobin molecule so that a low-level SaO2 will result in further complications related to the brain, and cardiac muscles (Chang, 2013; Vos, Folgering & Van Herwaarden, 1995).
Question 3: Patient-centered-nursing goals
• Pain (Score 7 on a scale of 1-10): Assessment of pain severity check on a regular basis along with vital signs on every 4 hours through asking the patient. Analgesics like NSAIDs will be provided to the patient every 4-6 hours. The patient will be educated for self-pain management and encouraged to take rest. The pain will vanish in next two days.
• Fluid loss or deficit: Receive patient’s response. Improve circulating blood volume, balance fluid volume and increase the urine output up to 1300 ml/per day. Target to reach the goal and assess whether it is achieved in next four days.
• Poor circulation (right leg is cool to touch): Receive patient’s response to touch, feel and sensation at the surgical site, hypovolemia management is required.
• Increased blood glucose level of 17mmols/ltr: Targets to lower the BGL level. help him to cope, and target to balance the insulin level in the circulating blood.
• Breathing problem (increased Respiratory rate 24BPM): Hypovolemia management and help him to deal and explain breathing exercises.
• Elevated temperature 37.9°C: Regular monitoring, and medication to lower temperature each 4-6 hours. Achieve normal temperature in next two days (Gögenur et al., 2007).
• Low SaO2 95%: Increase SaO2 level by next day, explain him the reason and educate him to cope (Carpenito-Moyet, 2006).
Question 4: Two identified goals and nursing interventions
• Pain (Score 7 on a scale of 1-10): • Pain (Score 7 on a scale of 1-10): Acute Pain after the fracture episode is a regular thing that contributes to discomfort. It is subjective which was estimated to be 7 on the pain scale. In the case of Mr. Jensen, pain is the primary problem that needs to be managed to prevent further complications of delay in his recovery.
In an evidence-based multidisciplinary collaborative intervention conducted by Gregory and Haigh (2008), the pain management strategies are explored and claimed that the efficient and multi-disciplinary pain management is a universal response provided by health care professionals to the patients which are similarly important in this case.
The pain scale is 7 which demonstrate it will be categorized into severe pain. The nurse will give stronger opioid for + acetaminophen or NSAID +/– adjuvants. Patients will receive medicines on each 4-5 hour gap through oral administration. The regular dose will help in constant pain relief and reduce the pain episodes. The target is to avert pain episodes instead of reaction against pain. By next day the severity of pain may reach moderate scale, the types of analgesics will be changed with weaker opioid + acetaminophen or NSAID plus adjuvants if required. Assess medicine effects closely due to pharmacodynamics and pharmacokinetics of drugs in older age.
The patient will be given 15-30 mg p.o. q4h dose of opioid (stronger opioid: morphine sulfate or hydromorphone) and Weak opioids (hydrocodone and codeine). The dose of acetaminophen or NSAID will be 20-30 mg p.o. q4h dose. Adjuvants: 25-150 mg p.o. q.h.s. (monitor levels).
Strong analgesics, like opioids (opium, morphine, codeine) attach themselves to the receptor sites of pain located in the brain thus inhibiting the path of pain signals. They do not restrain the central nervous system delivering a painless feel. But they work temporarily; it should be given on each 4 hours. Mild analgesics like NSAIDs and acetaminophen interfere with the pain source and alter the substance production responsible for the problem.
The nurse will closely monitor the efficacy and side-effects of prescribed drugs. Morphine often results in constipation thus will be given with laxative.
Adjuvant medicines that may include antidepressants, muscle relaxants, or anti-seizure medications, are valuable for pain management when administered with analgesics.
The non-pharmacologic means provided by the nurse can be divided into two categories: physical and psychosocial modalities. In physical intervention heat therapy and immobilization will be recommended by nurse initially, but as the pain will reduce light massage and mobility exercises will be suggested (after 4 days). The psychosocial interventions will be provided to the patient like family counseling, self-management education, biofeedback, and psychotherapy.
Through receiving regular feedback and estimating pain on pain scale, the nurse will measure the achieved level of interventions (Gregory & Haigh, 2008; Ramsay, 2000)
• Fluid loss or deficit:
The secondary problem of Mr. Jensen is reduced fluid volume. There are multiple possible impacts due to the fluid loss which in this case, is caused by surgery. The first step of intervention is to improve the circulating fluid and blood volume in the body. For this first, the characteristics of the diagnosed problem will be assessed like lower urine output, weakness, highly concentrated urine, high body temperature, hypotension, dry skin and tongue and increased thirst. The primary target of this nursing intervention is to balance fluid volume, hydration and to check the nutritional status of the patient. The expected outcomes, in this case, is to increase the urine output that should be 1300 ml/per day. To maintain blood pressure, body temperature, moisture and to prevent further fluid loss are the achievable outcomes of the intervention.
In a randomized clinical trial, Lobo et al. (2002) assessed that the evaluation of salt and water level in the body might result in faster recovery and help in achieving the outcome at a faster rate. As in this case patient can take fluid orally, so through oral administration, the water and salts can be provided. This intervention involves a regular assessment of dietary intake, bowel functioning, and fluid administration.
For this case, the nurse will employ fluid management based intervention using IV fluid and later on, the nurse will try to achieve normal levels of water and salt inside the body. It will help in averting further infections or complexity in the body. The first day after taking a concentrated electrolyte mixture will be provided through IV and then through assessing the symptoms and signs it will be diluted accordingly.
That is an efficient intervention to prevent the further complexities possible due to fluid loss and diabetes. It will improve the recovery pace.
The expected outcomes of these inventions are improved the circulating volume of blood, normal pulse rate and blood pressure. The positive water and salt balance are enough to increase the weight around 3 kg post surgery. Thus, through observing weight and relevant symptoms the nurse will measure the success of the intervention and achieved outcome rate. It will help in lowering the hypoperfusion risk, inflammatory mediator secretion and produces the better effects on a post-operative recovery (Lobo et al., 2002).
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