You are working in the High Dependency Unit and caring for Mr Paul Lester, a 68 year old man, who is day two post-op following an elective repair of an abdominal aortic aneurysm. The surgery was performed via a laparotomy, took several hours to complete and was uneventful. Mr Pearson weighs 90kg.
Current plan of care includes:
• Abdominal drain
• Right subclavian central line with Hartmanns at 100mls/hour
• Urinary catheter on hourly urine measure
• PCA Morphine with a bolus of 1mg
• Generally fit and well prior to discovery of aneurysm in routine health check
Clinical assessment findings
• Respiration rate: 26 breaths per minute
• Maintaining own airway on a simple Hudson mask at 6 L/minute
• SpO2: 96% ( on 6L O2)
• Blood pressure: 90/50 mmHg
• Heart rate: 130 beats per minute
• Monitor: sinus tachycardia
• CVP: 3 mmHg
• AVPU: alert but feeling light headed
• Abdominal drain: draining blood stained fluid - 400 mL in the last 2 hours
• Urine output: dark coloured urine 30ml/hr for the last 3 hours
• Cool, pale peripheries
• Pain score: 5/10
• White blood cells: 5 x 10⁹/L (4.0 - 11.0 x109/L)
• Urea: 8.5 mmol/L (3.0 - 8.5 mmol/L)
• Creatinine: 0.12 mmol/L (0.06 - 0.12 mmol/L)
• Potassium: 6.0 mmol/L (3.5 - 5.0 mmol/L)
• Haemoglobin: 75 g/L (130 - 180 g/L)
Arterial Blood Gas results
pH 7.32 ( 7.35 - 7.45)
PaO2 90mmHg (80 - 100mmHg)
PaCO2 32mmHg (35 - 45mmHg)
HCO3 24mmols/L (24 - 28mmols/L)
1. Analyse the data provided and explain Mr Pearson's clinical presentation, assessment findings and blood results and relate this to the pathophysiology of hypovolaemia.
You noticed that Mr Pearson has a reduced level of consciousness. You are concerned that he is deteriorating.
2. Describe and provide a rationale for your immediate nursing assessment and immediate interventions
The doctor reviews Mr Pearson and decides that he is hypovolaemic.
The doctor orders: a bolus of 500mL of gelofusion, to be followed by 0.9% NaCl solution at 125mL/hour. The doctor has also ordered a unit of packed cells.
3. Provide a rationale for the revised plan of care. Include in your answer the evidence and research about fluid resuscitation.
4. Write a brief reflection describing what you have learned from this assignment, your strengths and areas where you need to improve
Your first, and most reliable instrument in assessing Mr. Lester is your eyes. What do you see? Here's a man who is tachypneic, with cool, pale extremities and a 5/10 pain level. It appears he's demonstrating a sympathetic nervous system response, but is it post-operative pain, or inadequate tissue perfusion? Which of those will kill him?
Inadequate tissue perfusion is the definition of shock and it will kill if not treated, so your first task is to see if there are corroborating data suggesting shock. His CVP is the most critical information since it is essentially a dipstick for measuring his volume status. What is a normal CVP? (Hint: it isn't 3...) Also Mr. Lester is mildly hypotensive, and tachycardic with an okay, but lower than expected SaO2. Keep in mind that even at 6L/min by facemask, intra-tracheal oxygen concentrations will be no more than 27%, so an individual with chronic lung disease, or significant airway closure (68 year old lying supine with splinting from an abdominal incision) will have less than optimal SaO2 levels, due to intrapulmonary shunting in this situation. His urine ...
This solution analyzes the patient's condition by observation and instrumentation to determine the source of the sympathetic response. A detailed explanation is provided for hypovolemia and appropriate treatment given, and a reflection is included.