NSB236 Integrated Nursing Practice 3
Question:
Review given case scenario and write a report on it.
Part 1:
You are required to consider the associated signs and symptoms of your chosen condition and discuss the findings as they relate to each part of the ABCDE pneumonic. You need to be able to critically explain the link with the associated signs and symptoms, the pathophysiology/physiology and what the physical assessment identifies.
Part 2:
Having completed your physical examination of your chosen condition you are required to construct a structured written handover to the doctor using ISBAR.
Maureen Hardy is a 77 year old women who has been sent in by her GP for review who has had two episodes of haematemesis at home. Four hours after arriving on your ward she vomits blood and has blood around her mouth, you also note that she appears pale, sweaty and drowsy. Maureen is responding only to verbal stimuli on the AVPU scale. She has been taking the following medication:
- Diclofenac Acid 50mgs PO (with food) BD for arthritic knees
- Warfarin 2mgs PO mane for atrial fibrillation (INR 2.7)
Her observations are:
- BP 80mmHg systolic
- HR120bpm and irregular
- Resps 28bpm
- SaO2unreadable
- Capillary refill time >4secs
- Temp 36.5°C (core)
You also note that her pupils are dilated 3-4mms but are equal and reactive to light. She has equal bilateral chest movement and the depth of breathing is normal. She has a slightly distended abdomen.
The lab results have also arrived which show:
- Haemoglobin 9g/dL (12-15g/dL)
- Platelets 150000 (100,000-450,000K/uL)
- Haematocrit 27% (36-44%)
And her ECG reveal sinus tachycardia:
Frank James a 72 year old man has been admitted to your ward with an acute exacerbation of his chronic heart failure. He is positioned in a semi-high fowler’s position, is mildly diaphoretic, slightly short of breath and complaining of nausea. Mr. James has a history of stable angina for an undetermined period. However, he has revealed that for the past 3 weeks, he has been experiencing pain radiating to his back every hour, which is relieved with sublingual nitroglycerin (GTN). There is a family history of cardiovascular disease with an older brother dying from a myocardial infarction (MI) and a sister who has had 3 MI’s. Mr. James has a 30 year history of cigarette smoking and continues to smoke 1 pack/day. He has been taking the following medication:
- Aspirin 7mgs PO mane
- Atenolol 50mgs PO mane
- Isosorbide mononitrate 30mgs PO nocte
- Lisinopril 10mgs PO mane
The next morning Frank continues to complain of shortness of breath and restlessness with a chest pain score of 8/10 that is radiating to his left arm. The MO orders an urgent chest x-ray and it is noted in his medical notes that his heart failure is worsening and he has developed pulmonary oedema. On examination he is confused, sweating, pale and centrally cyanosed.
His observations on admission and currently are as follows:
|
On Admission |
|
Currently |
|
|
|
|
Am |
Pm |
|
§ |
BP 156/98mmHg |
140/100mmHg |
BP 96/50mmHg |
|
§ |
HR 124 |
HR 130bpm |
HR 128bpm |
|
§ |
Resps 30bpm |
Resps 28bpm |
Resps 36bpm |
|
§ |
Temp 37°C |
§ SaO2 92% |
U/O 20mls/hr for the past |
|
|
|
FiO2 |
2 hours |
His 12 lead electrocardiogram (ECG) reveals Q waves, ST depression and T wave inversion which may signify ischemia.
His chest x-ray reveals diffuse infiltrates that resemble “bat wings” consistent with pulmonary oedema.
Answer:
Part A
In the given case study, Maureen Hardy, a 77-year-old woman had two episodes of haematemesis and she vomited blood. The case presentation shows that among the four types of shock, the patient suffers from hypovolemic shock, as there is loss of blood due to gastrointestinal bleeding. There is acute external blood loss and severe gastrointestinal bleeding which is the main cause for the hemorrhagic shock. This shock results from significant internal bleeding into abdominal cavities. Hypovolemic shock is secondary to hemorrhagic shock in which there is rapid blood loss.
The main cause for the patient’s blood loss may be due to abdominal aortic aneurysm (AAA) as she had a slightly distended abdomen (Kent, 2014, p.2101-2108). Hemorrhagic shock occurs when there is reduction of tissue perfusion that results in inadequate oxygen delivery and nutrients that are necessary for cellular function (Kobayashi, Costantini & Coimbra, 2012, p.1403-1423). There is heavy bleeding, there is inadequate blood flow to the organs, and the symptoms of hypovolemic shock occur. External bleeding occurs which the symptom of internal bleeding. The patient in the case study has irregular heart rate of 120bpm and blood pressure of 80mmHg. The respiratory rate is 28bpm and capillary refill time is >4sec with unreadable SaO2. The body temperature is also low (36.5°C) and pupils are dilated. All thse signs and symptoms occur in hypovolemic shock due to acute blood loss.
The heart rate of Maureen Hardy is 120bpm that shows tachycardia condition with moderate hypovolemia (III) considered as stage III hypovolemia shock. This condition occurs, as there is reduction of blood volume in circulation to the lower venous return that is irrespective of the cause. In hypovolemia, there is arterial hypotension that is severe and there is compensatory systemic catecholamines release promoting peripheral vasoconstriction, tachycardia and increase in cardiac contractility. Tachycardial condition gives rise to increase in myocardial oxygen demand along with reduction in tissue perfusion that might result in myocardial failure. Therefore, the ECG of the patient showed sinus tachycardia (Vincent & De Backer, 2013, p. 1726-1764).
Another vital sign is blood pressure in hypovolemia below 90mmHg that is 80mmHg that is markedly decreased in hypovolemia. The reason behind this is vasoconstriction that decreases perfusion to pancreas, kidney, liver and spleen. There is narrow pulse rate in this shock as there is decreased cardiac output and an increase in peripheral vascular resistance. There is decrease in venous volume due to blood loss and so the sympathetic nervous system attempt to maintain or increase the falling blood pressure through the mechanism of systemic vasoconstriction. Therefore, the blood pressure of the patient is 80mmHg due to vasoconstriction that is not normal and requires further assessment of the skin colour, respiratory rate and mental status (Schlag & Redl, 2012, p.401-405).
The respiratory rate of the patient is also abnormal that indicate tachypnea (rapid breathing) 28 bpm as the normal rate is 12 to 20 bpm. There is shallow breathing in hypovolemia shock as there is increase in blood loss that can increase from 20 to 30 percent. There is abnormal breathing rate of patient that raises the breaths per minute (Buerke et al., 2011, p.73-83). The capillary refill time (CRT) is less than two seconds in a normal person that is measured by pressing the sternum with thumb or finger for five seconds that notify the time when the colour of the skin return to normal after the pressure is released. This CRT is more than 4 seconds in the patient that indicates the dehydration and less amount of blood flow to the tissues. This prolonged CRT indicates signs of shock, dehydration and decrease in peripheral perfusion. This increase in CRT made the skin turn pale, cool, sweaty and drowsy in the patient when the nurse assessed the skin colour (Pickard, Karlen & Ansermino, 2011, p.120-123).
The body temperature is also 36.5°C indicates massive drop in the core body temperature of the patient. This occurs due the body went to hypvolemic shock with acute external bleeding and condition of hypothermia. At the same time, the mental status is also taken into consideration where it is showed that patient responded to verbal stimuli on “alert, voice, pain, unresponsive” (AVPU) scale. The patient responded to verbal stimuli indicated that she has some kind of respond when the nurse speaks and pupils are dilated that is abnormal response to shock called mydriasis (Meyer et al., 2013, p.93-100).
After the identification of the vital signs of the patient in diagnosed with hypovolemic shock, it is important to relate each sign and symptom to ABCDE approach for better understanding. This approach explains A-airway, B-breathing, C-circulation, D-disability and E-exposure. Airway in hypovolemic shock is the assessment of airway obstruction in the upper and lower airways (Thim et al., 2012, p.117). This case study indicates upper airway obstruction as the patient vomits blood and as a result, there is loss of blood from the blood indicating haemoglobin of 9g/dL. Breathing is assessed through looking for the sweating, skin colour, abdominal breathing, depth and rate of breaths along with equality in chest movements (Frost & Wise, 2012, p.5677). In the given patient condition, although there is bilateral chest movement, abnormal rapid breathing occurs in the patient with normal depth of breathing. In all cases of hypovolemia shock, circulation is assessed in the patient. In Maureen, circulation is indicated in a way where there is uncontrolled external bleeding through vomiting, tachycardia, skin is cool, pale and sweaty (Pearson, Round & Ingram, 2011, p.387-389). For the circulation assessment, the capillary refill is low; blood pressure is low with decrease in pulse pressure indicating arterial vasoconstriction. There is also decreased tissue perfusion and reduced pulse rate. Disability approach includes examination of pupils (shape, size and reaction to light) on the AVPU scale. In the given case study, the patient has dilated pupils and only responded to verbal stimuli indicated Voice on the AVPU scale. Exposure is the exposure of full body for the physical examination ensuring dignity and respect with focused assessment of dorsal and frontal aspects of the body (Estes, 2013, p.285-289). In this, vital observations are taken into consideration like blood pressure, fluid balance, medical history, haematology and reassessment of ABCs to monitor the vital parameters of the patient. The patient history is also assessed comprising of medications like beta-blockers, Warfarin. Among all these, for the physical assessment, ABC approach- airway, breathing and circulation is considered in case of hypovolemic shock (Cap & Hunt, 2015, p.96).
Part B
ISBAR Clinical Handover
Identify the client:
The patient is a 77 year-old patient named Maureen Hardy who was sent to GP for the review as she had encountered two episodes of haematemesis while she was at home. After she reached the ward, she vomited blood and had a sightly distended abdomen.
Situation:
Currently, the patient is vomiting blood and her skin appears pale, cool and sweaty. She is only responding to verbal stimuli as recorded in AVPU scale. Her vital observations shows that she is having low blood pressure (80mmHg), high heart rate (120bpm and irregular), abnormal respiratory rate (28bpm) and slow capillary refill time (>4secs). Her pupils are dilated and distended abdomen. Her depth of breathing is normal and equal bilateral chest movement. It is also evident from the observations that she is suffering from tachycardia and tachypnoea. She also has a low core body temperature (36.5°C).
Background:
There is no such diagnosis done for the patient. However, the patient came to the hospital after she had two episodes of haematemesis while she was at home. Then she was said to visit her GP and after she reached the ward, four hours later, she vomited blood and her skin appeared pale, cool and sweaty. She was only responsding to verbal stimuli and her pupils were dilated. Her bilateral chest movement was equal with normal depth of breathing. However, she had a slightly distended abdomen. On examination, chest x-ray was normal and ECG showed tachycardia condition. She takes medication; diclofenac acid 50mgs PO for arthritis knees and warfarin 2mgs PO for the atrial fibrillation (INR 2.7)
Assessment:
The current condition of patient shows a lot of blood loss with increased breathing rate, low breathing rate, abnormal rapid breathing, unreadable oxygen saturation levels, low core body temperature and slow capillary refill time. Due to massive blood loss, the haemoglobin is 9g/dL. The patient also showed equal chest movement and normal depth of breathing. However, the patient’s abdomen is slightly distended,
The clinical signs indicate hypovolemic shock due to internal gastrointestinal bleeding. Due to severe GI bleeding, there might be acute blood loss from the body leading to hemorrhagic shock. The vital signs indicate that the patient is suffering from hypovolemic shock might be because of abdominal aortic aneurysm (AAA).
There is reduction of tissue perfusion that results in inadequate oxygen delivery and there is inadequate blood flow to the organs, and the symptoms of hypovolemic shock occur.
Recommendations:
After the handover, it is important to stop the external bleeding and acute blood loss. The multidisciplinary considerations comprises of the ABCDE approach that would be helpful for the appropriate assessment of the patient indicating hypovolemic shock.
Airway in hypovolemic shock is the assessment of airway obstruction in the upper and lower airways.
Breathing is assessed through looking for the sweating, skin colour, abdominal breathing, depth and rate of breaths along with equality in chest movements.
Circulation assessment, the capillary refill is low; blood pressure is low with decrease in pulse pressure indicating arterial vasoconstriction.
Disability approach includes examination of pupils (shape, size and reaction to light) and voice on AVPU scale.
Exposure is the exposure of full body for the physical examination ensuring dignity and respect with focused assessment of dorsal and frontal aspects of the body.
References
Buerke, M., Lemm, H., Dietz, S., & Werdan, K. (2011). Pathophysiology, diagnosis, and treatment of infarction-related cardiogenic shock. Herz, 36(2), 73-83. Doi: 10.1007/s00059-011-3434-7
Cap, A., & Hunt, B. J. (2015). The pathogenesis of traumatic coagulopathy. Anaesthesia, 70(s1), 96. Doi: https://onlinelibrary.wiley.com/doi/10.1111/anae.12914/full
Estes, M. E. Z. (2013). Health assessment and physical examination. Cengage Learning.
Frost, P. J., & Wise, M. P. (2012). Early management of acutely ill ward patients. BMJ, 345, e5677. Doi: 10.1136/bmj.e5677
Kent, K. C. (2014). Abdominal aortic aneurysms. New England Journal of Medicine, 371(22), 2101-2108. Doi: 10.1056/NEJMcp1401430
Kobayashi, L., Costantini, T. W., & Coimbra, R. (2012). Hypovolemic shock resuscitation. Surgical Clinics of North America, 92(6), 1403-1423. Doi: 10.1016/j.suc.2012.08.006
Meyer, M. A., Ostrowski, S. R., Overgaard, A., Ganio, M. S., Secher, N. H., Crandall, C. G., & Johansson, P. I. (2013). Hypercoagulability in response to elevated body temperature and central hypovolemia. journal of surgical research, 185(2), e93-e100. Doi: 10.1016/j.jss.2013.06.012
Pearson, J. D., Round, J. A., & Ingram, M. (2011). Management of shock in trauma. Anaesthesia & Intensive Care Medicine, 12(9), 387-389. Doi: 10.1016/j.mpaic.2011.06.005
Pickard, A., Karlen, W., & Ansermino, J. M. (2011). Capillary refill time: is it still a useful clinical sign?. Anesthesia & Analgesia, 113(1), 120-123. Doi: 10.1213/ANE.0b013e31821569f9
Schlag, G., & Redl, H. (Eds.). (2012). Pathophysiology of shock, sepsis, and organ failure. Springer Science & Business Media.
Thim, T., Krarup, N. H. V., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International journal of general medicine, 5, 117. Doi: 10.2147/IJGM.S28478
Vincent, J. L., & De Backer, D. (2013). Circulatory shock. New England Journal of Medicine, 369(18), 1726-1734. Doi: 10.1056/NEJMra1208943
Use the following coupon code :
SAVE10