Altered fluid balance (Hypovolemia)

Scenario 2 Part B: Altered Fluid Balance

Name of patient: Mr. Ron Fraser

Chosen Scenario number: Scenario 2-part B – Altered fluid balance (Hypovolemia)

List the cluster of cues related to the above priority problem in the identified scenario situation. Clearly indicate the cues which are abnormal and provide the normal ranges (with referencing) for comparison where appropriate.

Abnormal cue	Normal value	Reference
Respiration rate of 22 breaths per minute and shallow	Respiration rates 12-20 breaths per minute and moderate.	(Ogero et al., 2018)
Oxygen saturation of 92%	Oxygen saturation of between 94% to 100%	(Collins et al., 2015)
Pulse Rate of 116 beats per minute	Between 60 and 100 beats per minute.	(Hiemstra et al., 2019)
Blood Pressure of 90/60 mm/Hg	Blood pressure of 120/80 mmHg-140/90 mmHg	(Hiemstra et al., 2019)
Pain score of 8/10	Pain score of zero to 1	(Gan, 2017)
Blood Glucose of 14.2 mmol/L	Blood glucose range of 3.9 to 7.1 mmol/L	(Curnow et al., 2016)
Urine output of 10ml/hour	33 mm per hour to 83 mm Hour when an individual takes at least takes in 2 liters of water per day.	(Hiemstra et al., 2019)
Shallow breaths on command	Deep breaths on command	(Standl et al., 2018)
Dry Lips ad tongue	Moisturized Lips and Tongue	(Standl et al., 2018)
Empty PCA history	PCA history with some commands.	(Gan, 2017)
scant hem-serous ooze	Present Hem-serous ooze (normal during the healing process)	(Curnow et al., 2016)

Process information – Discuss Risk Factors and Contributing factors

Different risk and contributing factors can be attributed to the above mentioned cues that point towards hypovolemia. Bearing in mind that Mr. Fraser is a post-operative case, the signs of hypovolemia could have been caused by general anesthesia drugs(Noel-Morgan & Muir, 2018). Through the production of dose-dependent impairment to cardiac functions, any drug that is used for anesthesia purposes endanger cardiovascular stability. The drugs induce vasodilation, especially that reduce the overall venous return to the heart, delivery of oxygen to the tissues, and cardiac output. Secondly, the hypovolemia signs may have been caused by excessive blood loss intraoperatively. If heavy bleeding occurred while Mr. Fraser was undergoing Laparotomy and Right Hemi-colectomy, it might have precipitated the signs manifested. Without urgency in the correction of Fraser’s signs and symptoms, ischemic injury of the vital organs could set in, eventually leading to multi-system organ failure.

There could also be preoperative factors that led to the current hemodynamic by Fraser. For instance, extreme preoperative fasting may have been a contributing factor. A fasting period that goes beyond ten hours bound to reduce the intravascular volume. Clear oral liquids should be considered up to two hours preceding surgery. Underlying disease conditions may also have precipitated the current Fraser’s health condition. Pancreatitis and bowel obstruction are examples of conditions that precipitate fluid loss secondary to associated interstitial edema and inflammation (Garber et al., 2018). Finally, the patient may have had ongoing internal bleeding. Such situations call for surgical hemostasis and monitoring. Without that, there would be inadequate volume replenishment and increased chances of hypovolemia after Laparotomy.

Process information – Discuss Pathophysiology associated with the abnormalities and link to the present symptom (cues) with referencing

There is distinct pathophysiology associated with the different abnormalities enlisted herein. The increased respiration rate was as a result of a compensatory effort by Fraser’s lungs for the inadequate oxygenation of the tissues. It should be noted that following reduced fluid volume in circulation, the oxygen-carrying capacity of the blood was compromised and also led to the increased partial pressure of carbon dioxide (Collins et al., 2015). The two phenomena triggered the respiratory centers in the medulla to increase breathing rate. An almost similar mechanism can be used to explain the increased pulse rate of 11 beats per minute. Following fluid loss and impeding hypovolemia, the cardiac output becomes significantly reduced (Noel-Morgan & Muir, 2018). The change in blood pressure is detected by baroreceptors, and reflexive changes in the autonomic nervous system are evoked. Some of the changes include sympathetic outflow to the blood vessels and heart. In the scenario given, the sympathetic effect caused increased heart rate that in turn increased the pulse rate in an attempt to yield effective cardiac output and tissue oxygenation.

There were other physiological abnormalities that can be explained. The Blood Pressure of 90/60 mm/Hg, which is significantly low, was due to hypovolemia. Notably, the amount of body fluid has a direct impact on the measure of blood pressure (Hiemstra et al., 2019). The pain score of 8/10 indicated severe pain as a result of immobilization, lethargy, and general weakness of the patient (Standl et al., 2018). The PCA history was empty, meaning that the patient was not energetic enough to initiate pain control measures. TheUrine output of 10ml/hour could be associated with reduced fluid volume in the body, reduced afferent arteriole pressure, and reduced fluid intake. Despite the patient being on oxygen therapy, the suppressed respiratory system and inadequate tissue oxygenation secondary to hypovolemia greatly compromised the metabolism. Subsequently, the energy yielded could not support effective breaths on command. Dry lips and tongue can also be associated with dehydration that resulted following hypovolemia.

Actual nursing diagnosis with related to and evidenced by statements

Goal of care including SMART outcome criteria

Priority Nursing actions (4) including specific detail

Rationales for each action (4) explained with in text reference

Altered fluid balance

(Hypovolemia)

Related to:compromised fluid regulatory mechanisms and excessive fluid loss.

Evidenced by: Increased pulse rate of 116 beats per minute, low blood pressure of 90/60 mm/Hg, increased respiration rate, dry lips and tongue, and reduced urine output at 10mls per hour.

Within the next 24 hours, Fraser should demonstrate improved blood pressure within normal ranges, improved urine output close to 30ml per hour, improved pulse rate to within normal ranges, and moisturized tongue and lips.

Initiate fluid replacement therapy. This would be done using crystalloid solutions, colloid solutions, and, if need be, blood. Normal saline and ringers’ lactate are ideal isotonic solutions of choice. To achieve the goal, the health professionals need to be conversant with the right type of fluid to be administered, establish the weight of the patient and assemble various resources like canula for IV access, avail crystalloids, and/or colloids and establish patient consent. Having laboratory results of the patient’s full blood count would help in order to avoid hemodilution.

Closely monitor Fraser’s vital signs like respiration rate, capillary refill, and blood pressure. The abovementioned should be monitored every two hours and readings documented. To achieve the above, the care professionals would need to have the consent of the patient and relevant assessment and documentation tools like stethoscopes, sphygmomanometer, pulse oximeter, and thermometers. The readings must further be recorded in the right documents.

Monitor the level of consciousness of the patient as well as their muscular strength, movement, and tone. A Glasgow Coma Scale is an ideal tool to utilize in this. To achieve the above, the nurses and other healthcare professionals ought to be well versed with the Glasgow coma scale and interpretation of various readings.

Monitor Fraser’s intake and output as well as urine gravity. Closely related to the above is the assessment of edema and weighing the patient. to achieve the above, the care providers should possess knowledge on the standard input and output, the existing fluid balance (whether positive or negative), whether the patient can feed on their own. In Fraser’s case, intravenous fluid replacement would be chosen over oral because it would correct the fluid deficit quicker and more efficiently.

The main reason for fluid replacement therapy is intravenous fluid replacement and compensation. Once in the circulation, the crystalloids like normal saline increase the blood volume. Increased blood volume means that cardiac output would increase, and so would be the capacity to circulate oxygen to the different body tissues.

Monitoring vital signs help decipher whether the patient is improving. Fraser was suffering hypovolemia and almost went into hypovolemic shock.

Monitoring the level of consciousness is a precautionary measure. The move is meant to rule out or confirm any impending coma. Decreased cardiac output and a Glasgow coma scale reading of 8/15 indicate high chances of coma, and appropriate measures ought to be taken.

Monitoring fluid input and output is essential in establishing the fluid stats of the patient and the kidney function. A negative fluid balance that is accompanied by adequate fluid intake could indicate a need for a focused urinary system examination. Monitoring the weight of the patient is essential in establishing patient prognosis and determining the amount of fluid to be administered per hour.

Reference List

Collins, J., Rudenski, A., Gibson, J., Howard, L., & O’Driscoll, R. (2015). Relating oxygen partial pressure, saturation, and content: the hemoglobin–oxygen dissociation curve. Breathe, 11(3), 194-201. https://doi.org/10.1183/20734735.001415

Curnow, J., Pasalic, L., & Favaloro, E. (2016). Why Do Patients Bleed? The Surgery Journal, 02(01), e29-e43. https://doi.org/10.1055/s-0036-1579657

Gan, T. (2017). Poorly controlled postoperative pain: prevalence, consequences, and prevention. Journal of Pain Research, Volume 10, 2287-2298. https://doi.org/10.2147/jpr.s144066

Garber, A., Frakes, C., Arora, Z., & Chahal, P. (2018). Mechanisms and Management of Acute Pancreatitis. Gastroenterology Research and Practice, 2018, 1-8. https://doi.org/10.1155/2018/6218798

Hiemstra, B., Koster, G., Wiersema, R., Hummel, Y., van der Harst, P., & Snieder, H. et al. (2019). The diagnostic accuracy of clinical examination for estimating cardiac index in critically ill patients: The Simple Intensive Care Studies-I. Intensive Care Medicine, 45(2), 190-200. https://doi.org/10.1007/s00134-019-05527-y

Noel-Morgan, J., & Muir, W. (2018). Anesthesia-Associated Relative Hypovolemia: Mechanisms, Monitoring, and Treatment Considerations. Frontiers In Veterinary Science, 5. https://doi.org/10.3389/fvets.2018.00053

Ogero, M., Ayieko, P., Makone, B., Julius, T., Malla, L., & Oliwa, J. et al. (2018). An observational study of monitoring of vital signs in children admitted to Kenyan hospitals: an insight into the quality of nursing care? Journal of Global Health, 8(1). https://doi.org/10.7189/jogh.08.010409

Standl, T., Annecke, T., Cascorbi, I., Heller, A., Sabashnikov, A., & Teske, W. (2018). The nomenclature, definition, and distinction of types of shock. Deutsches Aerzteblatt Online. https://doi.org/10.3238/arztebl.2018.0757

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