Hypovolemia occurs when there is a rapid depletion of the body fluid, which can lead to multiple organ failure. This occurs due to the insufficient circulating volume of the bl0odd or the body fluid, leading to subsequent inadequate perfusion of the fluids. It is a clinical condition, where there is a decrease in the blood volume relative to vascular compartment that. Hypovolemic shock is common in an individual due to acute internal loss of blood loss in the thoracic cavity an in the abdomen. Anesthetic effect can also lead to hypovolemia. It is evident from the case scenario, that the Eleanor has undergone a tumor surgery under prolonged anesthesia. According to Noel-Morgan and Muir, (2018) it has been found that anesthesia causes vasodilation that is related to an increase in the venous compliance, a reduced venous return and a lessened response to the vasoactive substances. Hypovolemia might remain latent in a patient depending upon the severity of the patient condition and due to impaired delivery of oxygen and perfusion of the tissue (Taghavi & Askari, 2018). Isovolemic anemia cam occur, in case the blood transfusion in not available and that is featured by a decreased content of the hemoglobin. As per the values of the case assessment it can be seen that the hematocrit count of the patient and the concentration of hemoglobin is less than the standard value, which can be related to hemorrhagic shock. One of the risk factors related to hypovolemia is that it lowers the cardiac output and also causes hypotension. This occurs by the decreasing the preload. Low blood pressure is also visible in Eleanor’s assessment report (BP- 90/54), which is much lower than the standard value.
Trauma is common in patient who had undergone any crucial surgery like traumatic fracture or resection of a tumor. It can be due to hypovolemia, occurring due to the profuse blood loss.
The heart rate of Eleanor might is also high, which could have been due to the hypovolemic shock. Eleanor’s data has displayed low urinary sodium as the kidney tries to conserve the water and the sodium for expanding the extracellular volume.
The body compensates with the hypovolemia and an increased sympathetic tone by an increased heart rate, peripheral vasoconstriction and an enhanced vasoconstriction. Initially the changes that can occur physiologically is an increase in the diastolic pressure, with a narrowed down pulse pressure (Gulati, 2016). As a result of this the systolic blood pressure and the volume status continues to decrease.
Some other complementary mechanism has also been found to be involved in the body are the reflexes of the baroreceptors, chemoreceptors, the vasoconstrictors present in the circulation, the renal absorption of the eater and sodium, reabsorption of the tissue fluids and activation of the thirst mechanism (Gulati, 2016).
A prompt reduction in the arterial blood pressure is sensed by the body with the help of the arterial and the cardiopulmonary baroreceptors. As a result, the sympathetic adrenergic system is activated augmenting the contractility and heart rate. Hence, there occurs an increase in the systemic vascular resistance and the arterial pressure. Redistribution of the cardiac output occurs from the less important organ to the more important organ (Gulati, 2016). Vasocontriction is caused due to a reduction of the blood flow and a reduced arterial pressure. This reduced arterial pressure might cause systemic acidosis, detected by the chemoreceptors.
It is the combined impact of the sympathetic activation and the arterial hypotension that activates the humoral compensatory mechanism. It causes the sympathetic stimulation of the adrenal glands that causes the secretion of the catecholamines in to the blood reinforcing the impact of the sympathetic activation of the heart and the vasculature.
Hypotension in combination with the contraction of the precapillary resistance vessels leads to a drop in the capillary hydrostatic pressure (Lonjaret, Lairez, Minville & Geeraerts, 2014). As a result of the reduced capillary pressure, filtration of the fluid from the blood occurs in the interstitial space and the endothelium (Vincent & De Backer, 2013). Due to the reduction in the hydrostatic pressure, less amount of the fluid leaves the capillaries. With a fall in the pressure, there is a net fluid adsorption occurring from the tissue iterstitium back in to the capillary plasma (Vincent & De Backer, 2013). It is evident from the case scenario that the Hematocrit value of the patient was 0.36 that is higher than the normal value. This can be due to the fact that, there is an increase in blood plasma volume that causes a hemodilution of the blood, due to which the hematocrit value falls in response to the fluid shift.
Eleanor has returned to the ward after she had a right hemicollectomy with an adenocarcinoma that that is poorly differentiated. As per the assessment data four clinical priorities has been mentioned below-
A proper nursing goals has to be decided upon, before implementing them to practice. Nursing goals are meant to promote health and wellbeing for the community. It helps in providing a consistency of care and allow the multidisciplinary team to customize the intervention for each patients.
The nursing goals for the hypovolemic shock includes physical examination of the patient, that ca reveal low blood pressure, rapid heartbeat. Nurses should be able to diagnose heavy internal bleeding (if any).
The nursing goals appropriate for Eleanor would be the assessment of the low blood pressure after the Eleanor’s surgery. Proper approaches should be implemented for mitigating the incidence of post-operative hypovolemia. A nurse practitioners will diagnose lose blood pressure by checking the medical history and frequent vital assessment. Pharmacotherapy like Phenylephrine and Ephedrine should be administered, while giving the general anesthesia.
The nursing priority related to the vacuum drains will be to reduce the chance of the infections, during managing and discarding the drains. Drains are quite common features after any the big surgery for the drainage of the excessive fluid from the incision site. Hence the goal would be the management of the drains, preventing infections as infection and blockage of the drains are important complication related to the management of the drains.
Surgical sites are always susceptible to infection, hence one of the goal would be reduce the chance of infections at the incision site. Surgical sites are vulnerable to the accumulation of the puss, infected tissues that might led to edema. Nurses are accountable to conduct a regular review of the condition of the surgical site for checking color, temperature and wound edges.
The two most important nursing goals that has been selected for writing this part of the assignment is the management hypotension in the post operative period and the management of the surgical site and dressing.
Blood pressure management should not be overlooked in patients who had undergone such a big surgery as critical as a resection of a tumor. Hypotension in patients might occur in the post-operative period due to a varied number of factors like hypovolemia and prolonged effect of anesthesia. Hemorrhage after the surgery might have decreased the blood volume and have caused hypovolemia. Internal bleeding can be dangerous, hence it is the duty of the nurses to check for any signs of internal bleeding. Alagiakrishnan, (2015) have stated that internal bleeding can lead to trauma associated mortality and morbidity. If left untreated, it can cause serious conditions like multiples organ failure, coma and seizures. Low blood pressure can give rise to fatal conditions like multiple organ failure. Hypotension can cause clinical symptoms like tachycardia and decreased turgor of the skin. It can also lead to mesenteric or coronary ischemia (Alagiakrishnan, 2015). Tissue perfusion might be decreased that can decrease the cellular perfusion and death. In order to control these an early detection of the conditions is necessary (Bijker & Gelb, 2013). Vital signs of the patients should be assessed regularly. Etiology of the shock condition should be accomplished.
According to Mitra, Roy, Bhattacharyya, Yunus and Lyngdoh, (2013), timely application of the medications like Fludrocortisone, erythropoietin and Dihydroxy-phenyl Serine (DOPS)/Droxidopa can be given to the patient to reduce the hypotensive symptoms. A dose respondent study regarding the application of prophylactic infusion in the perioperative period and ephedrine in preventing hypotension has displayed a potency lof about 81:1. Phenylephrine and ephedrine are normally given to patients for reducing anesthesia induced low blood pressure.
Management of the surgical site has been chosen as another important nursing goal due to the array of complications related to the surgical site. Surgical site infections can occur up to 30 days after the surgery and tends to affect the incision and the deep tissue at the operation site. Despite of the improvements in the prevention, the surgical site infections remain a clinical priority as they are associated with mortality and morbidity and generally impacts severe demands on the various health care resources. The rise of the multi-drug resistant strain of mycobacterium has exacerbated the problem associated with surgical site infections (Anderson et al., 2016). In spite of the advancements in sterilization techniques, operating room ventilation, use of the ultraviolet lamps, the problems associated to infections have not subsided. The infection rate is after surgery is reported to be 9 % and 89 % of the total infections has been found to be after laparoscopic cholectomy. According to a research by (Karthik, Augustine, Shibumon, & Pai, 2013), it has been found that 30 % of the patient develops risk of seroma after a midline surgery. Seroma is the accumulation of the excessive fluid in the surgical site, if the exudates or the fluids are not drained properly. This might further lead to the formation of sepsis. As stated by Itatsu et al, (2014), incisional hernia can also form at the port site after a laparoscopic surgery. If the inscisional hernia is not treated on time, then it can form a protrusion at the site leading to the formation of a surgical scar. Another complication is the dehiscence of the wound. This can be prevented by proper inspection and dressing of the wound.
Conclusion
Tumor resection surgery in an elderly patient and bring about several complications in the post-operative period, 24 hours within the surgery. Low blood pressure in the post-operative period can be due to hemorrhagic shock and anesthesia given at the time of the surgery. Furthermore, the nursing priorities include hypovolemia, management of the hypotension, management of the vacuum drains, complications related to the surgical sites. The main aim of the nursing professionals would be a continuous monitoring of the pathophysiology of the condition, such that therapeutic relationship with the patients can be established and patient-centered intervention can be taken.
Reference
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