case study for advance acute care

Before answering the case study things to look at
-Please first read the answer the case study and answer it directly with the question provided
Doesnot have to be essay format.
-please don’t need the definition of Clinical reasoning cycle you just need to answer the Questions provided for Mr paul. Also just link everything with the patients with the given information regarding hypovolemia only.
– please use the clinical reasoning cycle by answering the question. just need to understand about hypovolaemia. So don’t go with other diagnosis.
-No dot point can just answer directly on hypovolaemicshock.MrPearson had a full laparotomy, day two post-op so he has lost fluid during laparotomy.

He is suffering from hypovolaemic shock so pathophysiological of hypovolaemic shock and relate to his clinical reasoning finding(journal article of hypovolaemic shock)

-question two is ABC assessment.
Pathophysiology of Hypovolaemia (link with pathophysiology of hypovolaemia with the patients more deeply and what is going to happens with angiotension hormones in details)
Loss of body sodium and consequent intravascular water; e.g. excessive sweating, diarrhea or vomiting what will happens to the electrolytes)
For example paul is suffering from hypovolaemia therefore has low Bp and high RR because the heart is trying to work hard.similarily need to describe other finding like why low urine output, Cool, pale peripheries
Need APA referencing and journal articles

-Reflection is your strength, what is your limitation, what you need to improve on this?
Case study

This assignment must be submitted electronically via Blackboard –Learnit – see instructions on page 31 – 32.
The grading rubric for this assignment is on page 14 – 15.
The purpose of this assessment is for you to apply the Clinical Reasoning Cycle to a case study. Nurses use the Clinical Reasoning Cycle in their daily practice to make decisions about patient care. Developing competence in using the Clinical Reasoning Cycle and making skilful decisions needs astute assessment skills, a sound knowledge base, the ability to integrate theory to practice and the courage to reflect on decisions and practice.
Therefore this case study will require you to interpret clinical data, describe nursing actions, use evidence to support decisions and for you to reflect on your knowledge, what you have learnt and to consider your future learning needs.
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
Past history
• 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
Blood results
• White blood cells: 5 x 10?/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)
Questions
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

The required format is (unless stated otherwise for an individual piece of work):
• Type assignment using 11 point font Arial
• Set margins
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• Align text left
• 1.5 line spacing
• Include a footer indicating
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Don’t need the definition of Clinical reasoning cycle you just need to answer the Questions provided for Mr Pearson .Also just link everything with the patients with the given information regardinghypovolemiaonly. Questions are as follows

Questions
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

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

Paul Lester Case Study
Clinical reasoning (CR) is a crucial skill for nurses (Carrier, Levasseur, Bédard&Desrosiers, 2012). To note, CR is the process through which “practitioners use to plan, direct, perform, and reflect on client care” (Schell, 2009, p. 314). Advance acute care nurses typically engage in clinical reasoning for several events experienced by a single patient in their care. Whereas experienced nurses are quite skilled in CR such that they can single out
important data, derive conclusions about a patient’s condition and decide upon the appropriate care that must be delivered, it must be emphasized the CR is learned rather than being based on intuition (Benner, Hughes & Stephen, 2008). One way to develop CR is through the use of frameworks such as the Clinical Reasoning Cycle (CRC). Briefly, the CRC is comprised of eight steps, namely, (i) considering the patient’s situation; (ii) collecting cues and information; (iii) processing information; (iv) identifying problems and issues; (v) establishing goals; (vi) taking action; (vii) evaluating outcomes; and (viii) reflecting on processes and new learning (Levett-Jones, et al., 2010). The CRC will enable the nurse to assess the patient’s situation, his or her symptoms, clinical presentation, and come up with the right plan of care. This paper presents a case analysis on Paul Lester using the CRC.

Pathophysiology of Hypovolaemia (link with pathophysiology of hypovolaemiawith the patients more deeply and what is going to happens with angiotension hormones in details)
Hypovolaemia, or reduced volumes of circulating fluids, takes place when fluid from the vascular space is lost to the external environment. In other words, it refers to the loss of blood as occurs when an individual has a haemorrhage (Formulary, 2001). Hypovolaemia can also occur when fluid is loss to interstitial space, such as in the loss of fluid and protein because of decreased plasma proteins or increased capillary permeability (Formulary, 2001). Loss of fluid because of reduced quantities of plasma protein, especially albumin, and the resulting reduction in colloid osmotic pressure, may occur among patients with burns and other wounds, kidney disease, or liver disease (Formulary, 2001). On the other hand, loss of fluid because of increased capillary permeability typically occurs among patients with sepsis, prolonged ischemia, or burns. Acute hypovolaemia may also be caused by severe vomiting or diarrhoea, or any other excess loss of body fluids.
Using the CRC, the salient factors about the patient’s situation are the following. Mr. Lester is 68 years old, day two post-op following an elective repair of an abdominal aortic aneurysm (AAA), and weighs 98 kgs. He has a PCA, morphine, and an IV running at 100mls/hour. He has low BP at 90/50, abdominal drain draining blood stained fluid at 400 mL in the last two hours. The patient was alert but feeling lightheaded, and has now on a lower level of consciousness.
The second step would be to collect relevant cues and information. Mr. Lester’s current observations have to be reviewed. (don’t need to mentioned this all, pleases answer question accordingly everything related with hypovolamia and with current APA reference
1. Sp02 : 96%
2. Pulse rate : 130
3. Blood pressure : 90/50
4. Hourly urine output (average) : 30mL/hr for the last three hours
5. Haemoglobin: : 75 g/L
6. CVP : 3 mmHg
7. Pain : 5/10
8. High blood potassium: 6.0 mmol/L
9. Low haemoglobin: 75 g/L
10. Low pH < 7.35
11. Low PaCO2: 32 mmHg
The third step would be to gather more, or review existing, information, including, the
temperature of the patient, skin turgor, new measurement of body weight, tongue/mouth dryness, mucus membranes dryness, and, sinus tachycardia. The fourth step would entail recalling knowledge. For instance, the most important nursing observations relative to a patient’s fluid status are haemoglobin, pH, weight, urine output, and blood pressure (Shepherd, 2011). Among dehydrated patients, kidneys conserve water so that urine is dark, concentrated and reduced in volume (Sinert, 2005; Shepherd, 2011). To note, the patient’s potassium is higher than normal levels, which may indicate kidney damage. The level of haemoglobin is consistent with the patient’s condition because he has undergone a surgery of the abdomen that may have resulted to bleeding during the process. It is also important to determine the patient’s arterial blood gas results because there are two non-normal values. The pH is low, which puts the body in an acidotic level. However, the PaCO2 level is not high, eliminating the chance of a respiratory nature. This leaves the cause of the low pH to metabolic process. Since PaCO2 is low, this indicates that the patient’s body is compensating and trying to overcome the acid-base abnormality.
Meanwhile, sharp changes in body weight is a good indicator of hydration status. (Shepherd, 2011). Blood pressure can drop and respiratory rate may accelerate especially if fluid loss is severe (Shepherd, 2011). Lester’s heart rate is at 130 beats per minute, which is higher than normal. This indicates that the body is losing fluid. Notably, hypovolaemic shock is defined by low cardiac output, poor tissue perfusion, and vasoconstriction (Formulary, 2001). It is clinically manifested through hypotension (systolic blood pressure <60 mm Hg), tachycardia, shallow rapid breathing, and mental confusion (Formulary, 2001; Shepherd, 2011). In Lester’s case, fluid loss can be attributed to the draining of 400 mL of blood-stained fluid from the abdominal area.
The next step would be to process the information at hand, and compared it to the symptoms and causes of hypovolaemia. Based on these, it appears that Mr. Lester is entering hypovolaemic shock due to dehydration. Dehydration is another common source of hypovolaemia, aside from trauma (Kreimeier, 2000). Loss of fluid in this type of patient is mainly comprised of plasma rather than whole blood as in the case of the trauma patient (Kreimeier, 2000). This means to say that if dehydration is the cause of Mr. Lester’s hypovolaemia, then his treatment plan will have to be changed.

Rationale for Assessment and Intervention(Loss of body sodium and consequent intravascular water; e.g. excessive sweating, diarrhea or vomiting what will happens to the electrolytes)
Mr. Lester is going into hypovolaemic shock because of dehydration. As observed in his physical condition, Lester is feeling light-headed, which is indicative of blood or fluid loss. The difference between shock and dehydration must be mentioned. Dehydration is caused by loss of water from the intracellular compartment because of hypernatremia (Berk & Rana, 2006).Therefore, it can occur among patients who are hypervolaemic, euvolaemic, or hypovolaemic. In contrast, hypovolaemia is caused by depletion of water from extracellular space because of excessive loss, such as from vomiting and diarrhoea, or inadequate intake of fluids. The immediate intervention that Mr. Lester needs is fluid resuscitation (Berk & Rana, 2006). This is because with nonhaemorrhagichypovolaemia, isotonic crystalloid solutions are usually given for intravascular repletion during shock and hypovolaemia (de Moya, 2013). Colloid solutions are not used but the Mr. Lester’s doctor orders for Gelofusion, which is a colloidal solution. Gelofusion can be used for blood plasma replacement as a result of haemorrhage, trauma, or dehydration. Gelofusion can increase blood volume, flow, and the transportation of oxygen. Patients with dehydration and adequate circulatory volume typically have a free water deficit, and hypotonic solutions (such as 5% D/W 0.45% saline) must be used for Mr. Lester (de Moya, 2013).

Rationale for Revised Plan of Care
If sodium is infused isotonically, water will not shift from intracellular to extracellular compartments; however, there will be a rise in fluid volume (Berk & Rana, 2006). However, if the sodium is added hypotonically to the serum levels, the intracellular volume rises. Due to the fact that dehydration is a sign that serum sodium levels are high, isotonic (normal) saline may be used to increase intracellular volume. This process is done over several days to prevent abrupt
changes in brain cell volume. In emergency cases such as that of Mr. Lester, halfisotonic saline may be infused so that his body will recover from the current state of shock and proper conditions are restored.
The doctor has correctly diagnosed that Mr. Lester is suffering from hypovolaemia as indicated by his symptoms. He needs to have the fluid in his body refurbished to avoid further deterioration of his condition, and a possible fatal change in his health status. If Mr. Lester does not receive the gelofusion and NaCl solution right away, his body is going to go into severe shock, which can lead to complications and worsening of his condition.

Reflection(can be used as first person)
This assignment is a good reminder of how important nurses are in ensuring that patients’ conditions do not deteriorate. Caring for patients in the hospital setting requires not only knowledge and skill but also the ability to detect changes in vital signs, clinical results, and physical indications. There is also a need to ask patients about how they are feeling because this can become a warning for nurses to take a closer look. The necessity of being vigilant and alert to changes in patients is more pronounced among those who are in delicate situations, such as those who have undergone major surgeries, because there could be changes in their conditions that can lead to fatal results if left undetected. As we know, there are many patients whose care have been deficient, resulting to avoidable medical errors.
This was a challenging task to accomplish but I nevertheless feel grateful that I was able to use the CRC as a framework for analysis. I believe that my main weakness is in terms of self-confidence. I believe that I was daunted by the terms “clinical analysis” and “critical analysis.” Although I knew that my thinking was on the right track, I continued to look for other possible options so that I could reach a well-founded conclusion. However, having a sequence of steps to follow means that the CRC will be easy to integrate into practice. I believe that my strength is in discerning what the “missing” clues are. These include skin elasticity, temperature, new measurement of body weight, and tongue/mouth dryness. I believe that intuition has much to do with it, and although I know this is contradictory with CRC, I simply had a deep hunch about dehydration. I was also persevering, particularly in determining what intervention should be given to Mr. Lester. I believe that this is a good attribute to keep simply because it shows dedicated pursuit of learning as well as a determination to overcome obstacles.
References
Benner, P., Hughes, R.G. & Stephen, M. (2008). Clinical reasoning, decision-making, and
action: Thinking critically and clinically. In, Hughes R.G. (ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville: Agency for Healthcare Research and Quality.
Berk, L. & Rana, S. (2006). Hypovolaemia and dehydration in the oncology patient. The
Journal of Supportive Oncology 4(9), 447-454.
Carrier, A., Levasseur, M., Bédard, D., &Desrosiers, J. (2012). Clinical reasoning process
underlying choice of teaching strategies: A framework to improve occupational therapists’ transfer skill interventions. Australian Occupational Therapy Journal, 59(5), 355-366. doi:10.1111/j.1440-1630.2012.01017.x
Formulary. (2001). Capillary fluid dynamics and pathophysiology of hypovolaemia.Formulary,
36 (1), 7.
Kreimeier, U. (2000). Pathophysiology of fluid imbalance.Critical Care4(2), 3-7. doi:
10.1186/cc968.
Levett-Jones, T., Sundin, D., Bagnall, M., Hague, K., Schumann, W., Taylor, C. & Wink, J.
(2010). Learning to think like a nurse. Retrieved from
http://journals.sfu.ca/hneh/index.php/hneh/article/viewFile/65/56
De Moya, M.A. (2013). Intravenous fluid resuscitation. Retrieved from
http://www.merckmanuals.com/professional/critical_care_medicine/shock_and_fluid_resuscitation/intravenous_fluid_resuscitation.html
Schell, B. A. (2009). Professional reasoning in practice. In: E. B. Crepeau, E. S. Cohn & B. A.
Schell (Eds.),Willard&Spackman’s occupational therapy (11th ed., pp. 314–327).
Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins.
Shepherd, A. (2011). Fluid balance. Retrieved from
http://www.nursingtimes.net/Journals/1/Files/2011/8/1/Fluid%20balanceCorr.pdf.pdf
Sinert, R. (2005). Clinical assessment of hypovolaemia. Annals of Emergency Medicine 45(3),
327-329.

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