NSB024: Nursing - Pathophysiology - Case Study - Assessment Answer

January 03, 2017
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Solution Code : 1AEBE

Question : Nursing Case Study

This assignment falls under Nursing Case Study which was successfully solved by the assignment writing experts at My Assignment Services AU under assignment help through guided sessions service.

Nursing Case Study Assignment

Case Scenario

Mr George Jensen, a 65-year old male, was brought into Emergency Department with an open fracture of his right tibia and fibula after falling from his roof while clearing the gutters. The following data were obtained on his admission:

nursing

He was taken to theatre as an emergency case where he had an open reduction and external fixation of his fractures. He has returned to your ward at 5.30am post-operatively. You have arrived on the morning shift to find:

  • His right leg is cool to touch;
  • Pain Score is 7 on a scale of 1-10;
  • Fracture site and pin sites are serous ooze with notable swelling of his right leg;
  • Blood glucose level of 17mmols/ltr;
  • His post-operative vital signs are currently, HR 107BPM, BP 104/55mmHg, temp 37.9°C Axilla, SaO2 95%, FiO2 6ltires via Hudson mask, Resp rate 24BPM;
  • Hartmans solution running at 125mls/hr via triple lumen central line situated in the right internal jugular.
  • Insulin and dextrose infusion running at 2mls/hr (2 units/hr);
  • Urine output via a Foley IDC is >1ml/kg/hr and dilute.

Applying your knowledge and understanding of Type 2 Diabetes, fractures and hypertension, you are asked to write an academic case study applying the following principles throughout your discussion:

  1. Explain, the pathophysiology of Mr Jensen’s post-operative hypovolemia and how some of his post-operative assessment data might have contributed to this. In addition explain how the body might compensate for this physiologically (approximately 800 words).
  2. Identify Mr Jensen’s actual PRIORITY problems. Justify each problem based on the data collected from Mr Jensen’s assessment data (approximately 400 words).
  3. For each problem identified, describe one (1) nursing goal for his care (approximately 200 words).  
  4. Choose two (2) of the identified goals, and justify, with a synthesis and an analysis of the evidence-based literature, nursing interventions with rationales to assist in achieving the identified goals. (approximately 800 words).

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Solution:

The pathophysiology of Mr. Jensen’s post-operative hypovolemiaMr. Jensen’s post-operative hypovolemia state is caused by the excessive bleeding common with fracture patients in the aftermath of fracture fixation. The pathophysiological process of Jensen’s post-operative state is comprehensive. First, hypovolemia is a condition whereby a patient’s level of blood reduces with a constant level of haemoglobin concentration. The excessive loss of blood led to the hypovolemia, which is also associated with a decrease in cardiac output and venous oxygen tension. According to Dunning (2014), the normal blood pressure of a person is 120/80 mm Hg. However, Jensen’s post-operative blood pressure was 104/55mm. This is a reflection of the substantial decrease of blood volume in the body due to hypovolemia. Additionally, the right leg was too cool to touch because of the reduction in the blood, which usually helps in thermoregulation. The hemorrhage experienced by Jensen culminated in a reduction in cardiac output. Additionally, the post-operative bleeding led to the impairment of the supply of oxygen to body tissues. In this regard, the oxygen utilization process is vital to underscore the impact of hypovolemia in Jensen. The total oxygen delivery is subject to the cardiac index and the arterial oxygen content. According to  Brandstrup (2012), arterial oxygen content is subject to the hemoglobin concentration in blood and hemoglobin oxygen saturation (Sao2). Additionally, the arterial oxygen content is also subject to the partial pressure of oxygen in the arterial blood. In Jensen’s case, the hemoglobin oxygen concentration is normal at 95% because a normal hemoglobin oxygen concentration for an adult is (95-100) %. This is a clear indication of the condition of hypovolemia, whereby the hemoglobin concentration in blood is constant as the blood volume decreases. In a normal setting, the body’s systemic oxygen consumption is almost equal to the metabolic rate of an individual.

In Jensen’s case, the blood loss deprived the body of energy and, led to the inadequate exchange of energy between the body tissues and the blood. Inzucchi et al. (2012) asserts that the hypovolemia state of the patient led to the increases of the fraction of inspired oxygen. The rate had to be maintained at a minimum of 6L/hr because of the state of the patient. The fact that Jensen was losing high volumes of blood meant that an ideal nasal canula had to be used to enhance high rate of inhalation to boost metabolism. In fact, the patient’s post-operative assessment reveals that the FiO2 rate was 6L/hr, which is an acceptable rate. However, there is need for use of a better nasal canula, which could boost the amount of oxygen inhaled. The canula used should also be designed in a way that carbon dioxide is not retained and inhaled. There is need for the improvement of the fraction of inspired oxygen. Therefore, the cardiac output leads to a substantial decrease in the supply of oxygen to various body tissues especially muscle tissues. The capillaries are left open leading to a failure to maintain the optimum tissue oxygen flux. Eventually there is a failure by the mitochondria to sustain the aerobic metabolism in the body.

In Wittenberg (2015) asserts that the normal urine output is (0.5-1) ml/kg/hr. Jensen’s is 1ml/kg/hr. This indicates that the urine output of the patient is on the high limit. Urinal output is closely relayed with the body’s metabolic rate. The high urine output is attributed to the reduction in blood in the body, which has increased the utilization of the low level of blood in performance of extra tasks. The low blood led to the reduction in blood pressure. The patient’s body temperature is 37.90C. The normal range of body temperature is (36.1-37.2) 0C. Therefore, Jensen’s body temperature is abnormally high because of the hypovolemia shock and increased rate of metabolism. The increased rate of metabolism is natural response of the body to a detection of low energy level in the body. However, there is frustration of such body process because the medium of energy is apparently inadequate. The infusion of fluids is vital, in this case, to enhance adequate nutrients in the body.

Hartman’s solution running at 125mls/hr via triple lumen central line situated in the right internal jugular is a manifestation of the Jensen’s need of mineral and nutrient. Such a solution is the best for a person who has undergone a fracture fixation. The solution is usually concentrated with minerals and nutrients. Jensen was also a diabetes-2 patient and was under medication. The patient’s glucose is also at 17.1mmol/L. However, the normal glucose level for a healthy adult is 11.1mmol/L (Lena, 2012). The post-operative glucose result indicates that Jensen has a high blood sugar level. The high blood sugar level is an indication of low insulin level or resistance of the patient’s insulin. For this reason, Jensen has type-2 diabetes hence the need for infusion of Insulin and dextrose infusion running at 2mls/hr (2 units/hr). Jensen’s pain level is at 7. The pain level is considerably high hence the need for administration of sedatives like morphine. According to Fraser, Brown, Forster and Brown (2014), morphine creates a barrier between the brain and blood. Consequently, the brain cannot receive the pain signals from the fractured area.

Prioritization of Jensen’s problems

Mr. Jensen’s severe pain should be attended to, by the physician before anything else because Jensen’s pain is at extreme level. Pain management of the patient should be prioritized because it will enhance the cooperation of the patient in treatment of their aspects. The hypovolemia problem should be resolved through infusion of blood of a blood group matching the patient’s blood group. However, the administration of Hartman’s solution should be maintained to enhance the patient’s stability. A low level of blood is risky because of the critical role of blood in the body’s physiological processes especially metabolism (Braun and Anderson, 2013). Additionally, the blood will enhance Jensen’s stability through the supply of energy to various body tissues. Adequate blood will stabilize the blood pressure of Jensen, which has dropped to a low level of 104/55mm. The infusion of blood for Jensen will help in the resilience of the patient’s heart beat rate, fraction of inspired oxygen, blood pressure and the body temperature. The normalization of the variables will enhance the recuperation of the patient in due time. The blood infusion is also critical compared to all other medical measures to be taken because Jensen will die if blood goes below a certain threshold. Death will render all other medical procedures null.

The reduction of the high glucose level in blood will also be vital because of the disturbance it causes in the physiology of the body. Lewis and Foley (2014) assert that the dysfunction of the insulin compromises the functioning of the kidney. Additionally, the body’s nutrient reserve is inadequate. The reduction of blood sugar is vital to prevent the formation of ketones. Additionally, there reduction of sugar reduces the restlessness associated with high glucose level in blood. Confusion is also prevented when the blood sugar level is reduced. The formation of ketones leads to the swelling of the brain and oedema. According to Kosova, Bergmark and Piazza (2015), the high blood sugar level will also lead to micro-vascular and macro-vascular diseases in the long-run. It can also lead to death in extreme cases.  The other problem of concern is the treatment of the fracture site, which is oozing with serous. The treatment will avoid the infection of the wound with germs. Additionally, the inflammation of the right leg will be reduced through the application of appropriate drugs.

Nursing goals

The pain problem of Jensen will require a pain relieving drug to ensure that the patient is at ease. The pain reliever will also enable the patient to cooperate in the subsequent treatments. According to Crossan and  Cole (2013), morphine cannot be used in pain management for a person who has a renal complication given that he was diagnose with diabetes mellitus in the past two years. The problem of hypovolemia will be resolved through a continuous intake of the Hartman’s solution and his blood group transfusion. The intake of Hartman’s solution ensures that he attains his normal blood level, which will lead to resilience in other variables including blood pressure and body temperature, metabolic rate and heart-beat rate (Atlee, 2012). The high glucose level will be resolved through the infusion of insulin to ensure that the extra glucose is converted into glycogen for storage in the liver for future use. The serous oozing will be stopped through cleaning of the body part and application of appropriate drug. The inflammation of the right leg will be reduced after the blood transfusion. The swelling was caused by the opening of the capillaries.

Literature review

According to Rejeski et al. (2012), the extracellular fluid volume deficiency problem can be eliminated through the continuous intake of the Hartman’s solution. The intake of the solution will compensate an individual for the loss of fluid after an operation. Additionally, it is important to have a plan on subsequent fluid intake. The individual suffering of hypovolemia must be conscious of his situation to ensure body hydration at all time. A personal initiative is crucial because of the need for quick regaining of the normal fluid level. The aspect of hypovolemia requires the patient’s preferred drink, which helps in the boosting of body fluid. The favorite drink will enhance adequate intake of the fluids hence quick recovery. The other measure, which can enhance the achievement of adequate body fluid, is the oxygenation through the use of the nasal canals, which prevent inhalation and retention of carbon dioxide (Allen, 2012). Additionally, the there is need for a good ventilation to enhance adequate oxygenation.

A balanced diet will also helps in quick recuperation from the hypovolemia state. The most reliable remedy to achieve normal body fluid is the infusion of hypertonic saline solution.  The frequent intake of water is also vital to achieve a normal fluid level within the body. The replacement fluids contain sodium lactate, which is similar to the extracellular fluid (Doherty and Buggy, 2012). There are few adverse effects of replacement fluids to the patients especially the post-operative cases. However, when the replacement fluid is used the volume administer must be triple the blood lost because just a third f the fluid remain within the cells. Sodium lactate is vital because it also helps in the hydration process. Hartman’s solution has lactate, which contains a bicarbonate precursor (Ding,   He, &  Xiao, 2013). However, the lactate never results in acidosis given that the solution also contains the sodium ion.

According to  Patil et al.(2012), the normal blood sugar level can be achieved through the infusion of insulin. Additionally, self-monitoring of the eating of sugary foods is also vital. Self-monitoring is the ultimate solution to high blood sugar level because it is important it enhances consciousness of the hyperglycemia state. The consciousness also serves as psychotherapy for the patients because they understand their situation. The adherence to insulin regimes is also vital because overdose has side-effects. The problem of hyperglycemia can be caused by several factors hence it is important for the patient to seek medical advice before taking of the insulin regimens (Perrier et al, 2013). Medical advice is vital because it makes the patient certain of the case of the high blood sugar. The cooperation between a doctor and the patient in the treatment of diabetes is vital.

According to Inzucchi, Bergenstal & Buse (2012), the monitoring of the blood glucose is vital because it guarantees early control of the diabetes. Exercise is also vital in achievement of normal glucose levels. Exercise leads to burning of excessive calories in blood. The continuous monitoring of the blood sugar level is also vital because it can easily lead to the detection of ketones in blood. When the blood glucose level exceeds 240mg/dl the patient must be having ketones in blood (Australian Diabetes Educators Association, 2016). Therefore, exercise is also limited in such cases. When a person excesses while having ketones in blood, the blood sugar level also increases exacerbating the hyperglycemia. The dietician is required for a person with high blood sugar level.  The dietician will provide reliable guidance on the foods to take in order to achieve normal level of glucose in blood.

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