Hypovolemic Shock, Pain Management, and Circulatory Management - Essay Example

Running head: Hypovolemic shock Name: University: Course: Tutor: Date of Submission: Question 1 Hypovolemic shock is an emergency condition in which severe fluid and blood loss results in multiple organ failure due to inadequate perfusion. Hypovolemic shock therefore can be perceived as a medical as well as surgical condition in which rapid fluid and blood loss makes it hard for the heart to effectively pump enough blood to the body causing many organs to stop working properly (Maier, 2008). The common symptoms of Hypovolemic shock usually comprises of a taste of sweetness, weakness, lightheadedness, dizziness, and even loss of consciousness. As far as the case of Mr. Kit Lee is concerned the first piece of data which shows diagnosis of Hypovolemic shock is RR 35 breaths/min, Laboured breathing, speaking in single words only and Decreased air entry on left side and asymmetrical chest wall movement (Tobias, 2000). Breathing problems and decreased air entry are major signs of Hypovolemic shock resulting from inadequate fluid volume in the intravascular space (Kolecki, 2004). This is usually caused by an absolute loss from an external source or in other cases a relative loss from fluid shifting from intravascular to Extravascular (Heitz, & Horne, 2006). The fluid shift is normally from the loss of intravascular integrity, increased capillary membrane permeability, or decreased colloidal pressure. Reduced levels of fluid circulation in turn cause a decrease in end diastolic volume. The decreased preload eventually results in a decrease in both stoke volume SV and cardiac output (CO) (Maier, 2008). The decrease in CO eventually leads to inadequate cellular oxygen supply as well as impaired tissue perfusion reducing oxygen supply in blood cells hence causing breathing problems which were recorded in Mr. Kit Lee’s case whose breathing was 35 breaths/min as well as he complained of having breathing problems (Ryan & Hamilton ,2008). The second piece of data which support diagnosis of Hypovolemic shock is BP 74/40 mmHg (MAP 51 mmHg), Apical pulse 120 beats/min but no radial or brachial pulses palpable. Individuals suffering form Hypovolemic shock tends to have a blood pressure of 80/60 mm Hg or less and a heart rate of 100 beats per minute or more (Hughes, 2001). This is normally caused by insufficient oxygen supply in the blood cells which causes them to die hence affecting effective blood and oxygen circulation in the heart (Ryan & Hamilton, 2008) .When heart fails to receive enough oxygen it stops working properly resulting to high blood pressure as well as increased heart beat. Moreover, from the assessment it is evident that the sonography for trauma (FAST) exam was positive usually a significant sign in patients suffering from Hypovolemic shock which is a third piece to support Hypovolemic shock (Ryan & Hamilton, 2008). Due to multiple organ failures rapid bleeding and fluid loss the skin is usually pale and cool causing confusion, drowsiness and unconscious as well as trauma. Mr. Kit Lee blood results showed a haematocrit of 0.24 which was caused by rapid bleeding which is a fourth piece of assessment that support diagnosis of Hypovolemic shock (Westaby, 2002).Acute blood loss as well as the redistribution of blood, plasma and other body fluid predisposes the injured patient to Hypovolemic shock resulting to the low levels of blood haematocrit which was noted in the case of Mr. Kit Lee. Question two Mr. Kit haemopneumothorax was as a result of the multiple rib fractures on the left side that he had sustained during the accident. Haemopneumothorax is a medical condition which occurs when the chest wall has been punctured causing blood and air accumulation in the pleural space (Westaby, 2002). This situation occurs when the air accumulates in the pleural specie without shifting the mediastinum or properly communicating with the atmosphere. When the chest wall and the pleural space have been punctured as result of an accident or injury, the blood, air or even in some cases both enters the pleural space during inspiration process but their accumulation hinders their effective exit during expiration (Kobayashi, 2005). The accumulated air in turn increases intrapleural pressure hence shifting the mediastinum as well as compressing the vena cava and decreasing venous return (Kee, 2003). The compressed vena cava and decreased venous return in turn leads to decreasing cardiac output. With decreased cardiac output, air and blood immediately rushes into the space in order to equalize the inside pressure with that of the atmosphere. This process eventually causes fluid disruption making it difficult for the two membranes to adhere to each other (Morock, 2009). The movement of the rib cage as well as lungs is eventually affected causing fluid. Fluid disruption makes it hard for the lungs to expand properly increasing the pressure in the lungs. The increased pressure causes the elastic tissues of the lungs to collapse causing haemopneumothorax condition as in the case of Mr. Lee. During the process the pressure in the lungs never drops as well as the air is not pulled into the bronchi making it hard for respiration to adequately take place (Lahey, 2006). The intercostal catheter and underwater sealed drain inserted will help resolve this problem. The inserted intercostal catheter will drain blood and air from the pleural space making it to return to a state of negative pressure a process which will make it to function normally (Lahey, 2006). On other hand the underwater sealed drain will allow evaluation of blood loss and re-expansion of the lung causing the lung to function properly leading to proper inspiration and expiration processes (Westaby, 2002). Question Three Pain management Pain management should be considered as the first priority intervention for Mr .Kit Lee given the fact that he is complaining of pain. Pain relief and management is usually considered a first and essential step especially in patients suffering from haemopneumothorax. Primarily the main aim of pain management especially in patients with critical situations as that of Mr. Kit Lee is allow for the most effective therapeutic option and physiotherapy to be carried out with the full co-operation of the patient (Miller, 2001). Since Mr. Kit Lee has suffered from a multiple of rib fractures and he is persistently complaining of pain it is necessary that the nurses and doctors in the accident room to administer effective pain control measures involving the injection of intravenous opioid analgesic agents and intracostal nerve blocks around the chest tube site (Klijn, 2008).Since Mr. Kit has fractured ribs as a way of reducing the pain, the nurses should administer to him an intercostals nerve block around the ribs of the chest which actually is an injection of local anaesthetic that provides temporary relief .This injection will help reduce the pain of Mr. Kit Lee by making the nerves that go to part of the chest wall numb hence in most cases it is normally used as part of an anaesthetic for an operation on the chest. In order to make Mr. Kit fall asleep for the nerve the nurses will be required to use it with the combination of a general anaesthetic (Westaby, 2001). Since already Mr. Kit Lee is complaining of pain the nurses should ensure that the intercostal nerve block is not a general anaesthetic since it will keep Mr. Kit Lee awake and more sedated making the situation even worse for Him. The block usually lasts for several hours making the chest numb during an operation. The advantage of using intercostal nerve is the mere fact that it reduces the amount of other strong painkillers such as morphine required during and after the operation (Newman, & Jones, 2001). The intercostal nerve block can cause sympatholytic effects to Mr. Kit Lee primarily as a result of blockade of the sympathetic chain resulting in hypotension. In this case it is necessary that the nurses ensure that proper care is taken. However, if Mr. Lee continues to complain of pain, a combination of local anaesthetic bupivacaine 37.5–50 mg h, ropivacaine 10–30 mg h– and opioid drugs such as Morphine, diamorphine and pethidine among others should be used. The combination of the two will significantly help in achieving better dynamic pain relief after the lower or upper abdominal (Spaniol & Knight, 2007). They should be administered to Mr. Kit Lee through a continuous infusion in order maintain to the required level of analgesia as well as to minimize the cardiovascular and respiratory effects of bolus doses of LA and opioid respectively. During this process it necessary that the nurses ensures that there is proper ventilation for effective respiratory process to takes place since epidural opioid usually causes respiratory depression. Due to the strong hydrophilic nature of some opioids such as morphine there is an increased tendency for the drug to remain in the CNS of Mr. Kit Lee especially in cerebrospinal fluid leading to a possible cephalad spread as well as delayed respirattendency for ory depression resulting in breathing difficulties. It is therefore important that proper ventilation and breathing mechanisms are provided for Mr. Lee such as Oxygen masks to ensure that respiratory does not occur (Miller, 2001). Circulatory Management Circulatory Resuscitation Measures The main objective of circulatory management is to ensure that the patient stops bleeding as well as oxygen restoration and delivery to all the tissues of the body is achieved effectively.. Since Hypovolemic shock is a result of blood and fluid loss, fluid resuscitation is usually a priority in the case of Mr. Lee (Spaniol & Knight, 2007). Intravenous fluid therapy is usually perceived as one of the most significant shock management techniques in most of the patients (Hughes, 2001). Early correction of the fluid volume deficits is usually vital in patients suffering from Hypovolemic shock since it helps prevent decline in tissue perfusion from becoming irreversible. Fluid repletion therefore should continue as long as Mr. Lee’s systemic blood pressure remains low. In such cases an adequate vascular access should be obtained through the insertion of at least two large bore cannulas (14-16 G).In addition influsion fluids containing crystalloids and normal saline should warmed to the body temperature. Isotonic crystalloids are the most preferred in the case of Hypovolemic shock than any other fluid solution since they have osmolatity ions similar to that of the plasma (Snow &, Richardson, 2001). A bolus dose of isotonic crystalloids which are equivalent to one blood volume should be administered to Mr. Lee for a period of 10-30 minutes depending on the severity of the recorded clinical signs. In various cases these fluids are usually used interchangeable hence it’s important that the nurses take proper care as far as Mr. Lee’s case is concerned (Plaza, 2007). Mr. Lee’s trauma test was positive and in such cases metabolic acidosis is normally poor as well as the secondary tissue perfusion hence the use of alkalinizing solutions may be beneficial in reducing Mr. Lee’s metabolic acidosis. In order to improve tissue perfusion intravascular volume replacement should be done which help in stabilizing the working of the body tissues (Snow &, Richardson, 2001). Though, 0.9% Nacl and Ringer’s are important especially in individuals suffering from Hypovolemic shock as they are considered to be acidifying solutions they should not be used as far as Mr. Lee’s case is concerned since there is possibility of them slowing down the resolution of the metabolic acidosis hence a slightly less acidifying fluid solution such as Hartmann’s should be administered instead (Ivatury & Shah, 2000). Careful patient monitoring should be done during the whole clinical process as well as important clinical parameters such as heart pulse, pulse quality, mucous membrane color, and capillary refill time are assessed frequently to ensure that the fluid rate remains appropriate. The nurses should ensure that the fluid rate is 4-10ml/kg which should be administered for sometime (Fernandez & Fontan, 2001). Since Mr. Lee showed signs of trauma the isotonic crystalloids should be used with caution to avoid creating pulmonary contusions which could furthermore hamper Mr. Lee’s breathing even more (Matthews, 2003). This is because in extreme cases as that of Mr. Lee fluid therapy of any type can easily increase the amount of pulmonary parenchymal hemorrhage creating edema to the injured lung tissues as well as respiratory distress. The physical examination should continue for sometime and in case Mr. Lee shows signs of poor perfusion then the remaining fluid bolus should be given to him (Peters, 2001). Once Mr. Lee has stabilized continued fluid therapy should be immediately addressed because a complete withdrawal of the fluids after the bolus normally results in worsening clinical parameters (Charles, 2005).Fluid crystalloid normally diffuse rapidly out of the blood vessels into the interstitial space hence only a small amount of initial bolus dose usually remains in the intravascular space after about one hour. In order to maintain the intravascular volume continued fluid therapy should be administered in the face of rapid redistribution. In relation to the fluid therapy blood transfusion should always be done (Snow &, Richardson, 2001). During the accident Mr. Kit lost a lot of blood which was one of the reasons behind his Hypovolemic shock hence Mr. Lee will require significant blood products in addition to the fluid colloids and crystalloids. The dose of blood would be given for one hour and this will ideally depend on ongoing blood loss (Evans & Gray, 2000). Since Mr. Lee had fractured ribs the nurses should attempt to ensure that internal ongoing bleeding is stopped as soon as possible. In order to stop further bleeding a peripheral artery ligation is done. Evaluation criteria The pain management measures should relieve the pain that Mr. Kit Lee is feeling before and after the Surgery (Evans & Gray, 2000). Since the main objective of circulatory management is to ensure that bleeding stops and oxygen delivery is adequately restored to all the tissues of the body, to evaluate if the priority is working Mr. Lee should stop bleeding and breathe normally (Canker, 2002). References Canker, S (2002). 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