• Internal Code :
  • Subject Code : NUR2203
  • University : University of Southern Queensland
  • Subject Name : Nursing

Post-Surgical Hypovolemia: Case Study Analysis

Introduction

Total Hip Replacement (THR) is an effective and relatively economical alternative surgical correction that commonly applied in dealing with severe joint pain that is mainly caused by the depletion of the tissue surrounding the joint area-osteoarthritis. A significant proportion of the population usually experience complications, and Prosthetic Joint Infections (PJI) is considered most severe. PJI is predominantly caused by Staphylococcus aureus or coagulase-negative staphylococcus (Bull, Worth, & Richards, 2012; Nickinson et al., 2010). Although the occurrence of PJI is uncommon, it has devastating effects on victims such as poor function, severe pain, and reduced quality of life which could even result in death (Moore et al., 2015).

The treatment costs are high for individuals and the overall health care system. Readmission is usually common, and the intricacies protracted; associated with more complications (Kunutsor et al., 2016). A large number of patients that require reversion for PJI is forecasted (Patel et al., 2015). PJI is a major public health problem that is global; in Wales and England alone, more than 1000 procedures that require revision are conducted annually because of PJI of the hip (Lenguerrand et al., 2017). The aim of present essay to discuss the case of a patient named Sarah Blake who underwent a total hip replacement surgery and encountered several complications in post-surgery phase.

Part B: Pathophysiology of Hypovolemia

Hypovolemia results from the recession of the intravascular volume, either by blood loss or extracellular loss of fluid. The body counters with a prolonged sympathetic tone that causes elevated heart rates, peripheral vasoconstriction, and heightened cardiac contractility. The initial deviation from normal levels for each vital organ is recorded in hypovolemic shock is the heightened levels of diastolic blood pressure accompanied by constricted pulse pressure. When the status of the volume dynamically decreases, the systolic pressure of the blood also drops. Consequently, the delivery of oxygen to primary organs is limited and does not match the demand. The respiratory process changes from aerobic to anaerobic metabolism that has negative effects of having lactic acid released.

The result is lactic acidosis. Since the sympathetic drive increases, the flow of blood is diverted from organs to allocate blood flow to the brain and heart. As a result, lactic acidosis and tissue ischemia worsen. If medical interventions are not administered, hemodynamic compromise continues to get worse and may lead to death (Gayet-Ageron et al., 2018). The Compensatory Reserve (CR) provides a paradigm shift in the processing of information on the pathophysiology of hypovolemia. The CR provides information on the total of the mechanisms of compensation that continues to maintain perfusion of the brain and heart during hypovolemia (Suresh et al., 2019).

History and Physical

The diagnosis of hypovolemic shock is determined by physical and historical factors. Given that Sarah had previously undergone hip replacement surgery, she faces an increased threat to hypovolemia due to the loss of fluids, hypertension, and hypercholesterolemia. The sign and symptoms that Sarah should expect are depletion of volume, and acid-base disorders, or imbalances of electrolytes. The presence of orthostatic hypotension, Obstructive Sleep Apnea (OSA), Myocardial Infarction (MI), and Osteoarthritis are inherent for patients with hypovolemia.

Continuation of hypovolemia may result in coronary ischemia, and mesenteric that is accompanied by chest and abdominal pain. When the patient further becomes agitated and confused, this may result in brain malperfusion. However, comparatively nonspecific and nonsensitive, physical scanning can help identify the presence of hypovolemia. Other physical results, such as decreased turgor of the skin, dry mucous membrane, and volume depletion can be observed. In the long-term, hypotension and tachycardic episodes can be accompanied by the reduction of urinary output. The patient who experiences this situation are often anxious, cyanotic, and clumsy (Annaneet al., 2013).

Possible Clinical Issues after Total Hip Replacement (THR)

The most vital complications related to THR surgery are those that are threatening to the overall wellbeing of the patient, such as complications associated with anaesthesia. The other complications, such as the difference in leg length, do not pose serious medical threats but have long-term effects on the quality of life and comfort of the patient. The complications relating to blood clots are one of the most critical medical issues that are related to joint replacement surgery. Thrombosis is the clot of blood in the leg; characterised by rapid increase development of swelling especially along the calf. Pulmonary embolus (PE) is the clot that cuts off and travels to the chest area, particularly to the lungs and heart. The condition is characterized by increased heartbeat and breathing rates. Moreover, different leg length after surgery is also expected. Although the orthopaedic surgeons plan and execute their operations with meticulousness, in some cases slightly shorter, the legs may be made.

Hip dislocation occurs when the prosthetic ball is dislodged off its socket. The procedure to return the joint back to its normal state does not require surgery; only anaesthesia abs hip back manipulation. Researchers speculate estimate that 1% to 3% of the people dislocate their hips; of which 40% of the population experience hip dislocation as a one-time event (Erik, 2020). Dislocation is more likely to older females who have previously undergone hip replacement surgery. Moreover, the presence of weak muscles that surround the hip, accompanied by osteonecrosis, and arthritis have also been shown to increase the likelihood of hip dislocation. Effects Stress in Blood Pressure

Stress because of surgery is the systemic nervous, endocrine, and immune response to the surgical injury. Although stress is commonly influenced by immunological changes, haematological changes are also common in contemporary practice. Stress that leads to depression is one of the psychological comorbidities that have negative effects on patients, especially those with cardiovascular diseases or hypertension. Stress and pain have compounding effects on causing hypertension. Given that Sarah has high cholesterol levels, high blood pressure accompanied by hypovolemia has undesirable clinical outcomes.

Part B: Identification and Justifications of Clinical Problems for Sarah.

Effective or optimal pain management by using analgesics and narcotics is key. Pain management is a critical aspect they determine patient comfort and overall well-being. Controlled analgesics for patients are the most commonly used method for effective pain management. Pain management is critical given that pain increases the blood pressure of the patient; which under this case is supposed to be checked. Maintaining the balance of the fluid is one of the most critical concerns for because of concerns of post-operative complications such as wound infection, pulmonary embolism, and Acute Kidney Injury (AKI). Moreover, there is hypotension and stress ulcers.

The maintenance of fluid equilibrium is important in maintaining the flaccid nature of tissues so that healing can occur. The monitoring of the blood pressure of the patient is key, given the immunological and haematological changes that are usually associated with post-surgical stress. In this case, vasopressin. Antidiuretic hormone or vasopressin plays the function of regulating the tonicity of the fluids in the body. As such, this is key given the precondition that Sarah was placed in the intravenous infusion of sodium chloride.

Controlling stress due to hormonal and post-surgical complications to expedite the recovery process. The provider ought to identify approaches for improving Sarah’s mechanism of coping. Medical adherence and quality of service will be achieved when proper stress management training is incorporated into the treatment process. Additionally, stress management for Sarah is key given the prognosis Obstructive Sleep Apnea (OSA) which coupled with hypertension and hypercholesterolemia may result in the development of cardiovascular diseases.

Additionally, patient awareness and education are also key, considering that Sarah has post-operative complications that may require the personal maintenance of the wounded site following occlusivehip dressing. Occlusive dressing usually requires the soliciting help from a caregiver. In the long-term, patient’s education and awareness might incorporate stress management therapies to further economize on costs. Nursing Goals for each of the problems identified

The monitoring of vital signs can provide useful insights for hypotension. Evaluation and tachycardia of the skin turgor are mandatory, given that mucous membranes and capillary are mandatory goals. Besides the usage of laboratory results, the nurse keeps the replacement of fluid controlled to balance hydration status. Away from that, stress management is an important aspect for the patient that have post-operative complications like Sarah. Prior studies have illustrated the efficacy of stress management methods like Cognitive Behavioural Therapy (CBT) in improving the mechanism of coping with stress (Philip, Kannan, & Parambil, 2018; Saito, Shiraishi, & Yoshinaga, 2019).

The inclusion of therapy sessions provides better platforms for the provision of education and awareness. CBT augments the pharmacological medical interventions that have been applied to Sarah’s complication (Farah et al., 2018). When the patient is offered both non-pharmacological and pharmacological medical interventions, the quality of service is considerably improved, and the recovery time is significantly heightened (Palermo et al., 2018). Given Sarah’s medical history of hypertension and hypercholesterolemia, stress management is important. A registered nurse ought to have hands-on knowledge and have professional experience in offering therapy sessions further to reduce the patient-provider information gap through health promotion; thus, RN ends up providing better quality and safe care that in turn improves patient satisfaction in the long-term.

The administration of Patient Controlled Analgesia (PCA) to Sarah will prove to be important in the reduction of pain. Coupled with the patient’s education and awareness. Medical adherence to the PCA as well as the other medicines can be bolstered with patient education and awareness, gave the necessity to self-manage the wound. Pain management is important, given that Sarah reports pain of 6 out of 10 on a scale. The focus on pain by orthopaedic nurses is because of the significant impact on patient comfort and overall well-being. Relatedly, wound complications or Surgical Site Infection (SSI) is also another key medical intervention that warrants immediate attention. Would and SSI often counter the effectiveness of pain management intervention. The proper fluid balance will be maintained by the use of Intravenous Intrusion of saline sodium chloride 80ml/hour.

Part C: Discharge Plan

Discharge planning process evaluation is increasingly important given the need to fostering health promotion using Electronic Healthcare Record (EHR); it is important in the event report reduction of the chances of readmission and medical adherence (Nordmark, Zingmark, & Lindberg, 2016). Evaluating will be conducted to make sure that Sarah has completely healed the post-surgical wounds and that there is no infection. Lab results will be checked to make sure that the fluid balance is maintained to optimal levels. Follow up therapy will be conducted until the completion of the entire CBT sessions. Away from that, discussion plans need to be planned and implemented on the necessity of averting alcohol and cigarette consumption by Sarah. Maintaining posture and sleep is an important thing to include in the discharge plan. Sarah must maintain the correct posture to make sure that the wound heals.

Additionally, given that Sarah smoked and took alcohol; transitional care units can be used to provide a platform for rehabilitation. The short-term rehabilitation centre or Transition Care Units (TCU) can augment the pharmacological and non-pharmacological approaches that have been used to treat and manage Sarah’s post-operative surgical complications (Brown,2018; Low et al.,2017). The placement of Sarah in TCU will get their medical treatment monitored and observations in line with the prescribed rehabilitation activities leading to a long-term, cost-effective method for both the patient and the doctor, respectively. Rehabilitation is warranted given the need for wound healing and recovery, and drug abuse lowers this period significantly. Moreover, alcohol and cigarette smoking may interfere with the fluid balance given preconditions of hyperopia.

Conclusion

Hypovolemia exists as a multifaceted post-operative complication that has subtle pathophysiology insults of the tissue and multisystem organ dysfunction in the short-term and long-term period, respectively. Early intervention leads to reduced mortality, while late intervention is often ineffective. Parameters, monitors, and vital signs that are typically used in intensive care unit limit detection and monitoring. The sum of the compensatory mechanism that sustains optimal tissue perfusion while under hypovolemia is the compensatory reserve.

Prosthetic Joint Infections (PJI), hip dislocation, deep vein thrombosis, and pulmonary embolism are the most common adverse effects of hypovolemia. Maintaining fluid balance, effective pain management, controlling stress, and proper wound management are the most appropriate intervention for the preceding medical threats posed by the onset of hypovolemia. Patient awareness and education is also a factor that is commonly conferred a norm for effective personalised health promotion given then needs for self-managed nature of the post-operative care. Furthermore, patient education and awareness are key for patient monitoring and medical adherence that could be incorporated in the respective therapy sessions to counter stress further and improve mood and medical adherence.

References

Annane, D., Siami, S., Jaber, S., Martin, C., Elatrous, S., Declère, A. D., ... & Trouillet, J. L. (2013). CRISTAL Investigators: Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: The CRISTAL randomized trial. JAMA, 310(17), 1809-1817.

Bull, A. L., Worth, L. J., & Richards, M. J. (2012). Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive Staphylococcus aureus surgical site infections: report from Australian Surveillance Data (VICNISS). Annals of Surgery, 256(6), 1089-1092.

Brown, M. M. (2018). Transitions of care. In Chronic Illness Care (pp. 369-373). New York, NY: Springer.

Erik, H.M. (2020). Total hip replacement surgery risks and complications. Retrieved from https://www.arthritis-health.com/surgery/hip-surgery/total-hip-replacement-surgery-risks-and-complications

Farah, W. H., Alsawas, M., Mainou, M., Alahdab, F., Farah, M. H., Ahmed, A. T., ... & Mohammed, K. (2016). Non-pharmacological treatment of depression: a systematic review and evidence map. BMJ Evidence-Based Medicine, 21(6), 214-221.

Gayet-Ageron, A., Prieto-Merino, D., Ker, K., Shakur, H., Ageron, F. X., Roberts, I., ... & Gilliam, C. (2018). Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients. The Lancet, 391(10116), 125-132.

Kunutsor, S. K., Whitehouse, M. R., Lenguerrand, E., Blom, A. W., Beswick, A. D., & INFORM Team. (2016). Re-infection outcomes following one-and two-stage surgical revision of infected knee prosthesis: a systematic review and meta-analysis. PloS One, 11(3).

Low, L. L., Tay, W. Y., Tan, S. Y., San Chia, E. H., Towle, R. M., & Lee, K. H. (2017). Transitional home care program utilizing the integrated practice unit concept (THC-IPU): effectiveness in improving acute hospital utilization. International Journal of Integrated Care, 17(4).

Lenguerrand, E., Whitehouse, M. R., Beswick, A. D., Jones, S. A., Porter, M. L., & Blom, A. W. (2017). Revision for prosthetic joint infection following hip arthroplasty: Evidence from the National Joint Registry. Bone & Joint Research, 6(6), 391-398.

Moore, A. J., Blom, A. W., Whitehouse, M. R., & Gooberman-Hill, R. (2015). Deep prosthetic joint infection: a qualitative study of the impact on patients and their experiences of revision surgery. BMJ Open, 5(12), e009495.

Nickinson, R. S. J., Board, T. N., Gambhir, A. K., Porter, M. L., & Kay, P. R. (2010). The microbiology of the infected knee arthroplasty. International Orthopedics, 34(4), 505-510.

Nordmark, S., Zingmark, K., & Lindberg, I. (2016). Process evaluation of discharge planning implementation in healthcare using normalization process theory. BMC Medical Informatics and Decision Making, 16(1), 48.

Palermo, T.M., Dudeney, J., Santanelli, J.P., Carletti, A., & Zempsky, W.T. (2018). Feasibility and acceptability of internet-delivered cognitive behavioral therapy for chronic pain in adolescents with sickle cell disease and their parents. Journal of Paediatric Hematology/Oncology, 40(2), 122-127.

Patel, A., Pavlou, G., Mújica-Mota, R. E., & Toms, A. D. (2015). The epidemiology of revision total knee and hip arthroplasty in England and Wales: a comparative analysis with projections for the United States. A study using the National Joint Registry dataset. The Bone & Joint Journal, 97(8), 1076-1081.

Philip, P. M., Kannan, S., & Parambil, N. A. (2018). Community-based interventions for health promotion and disease prevention in noncommunicable diseases: A narrative review. Journal of Education and Health Promotion, 7, 141. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6282482/

Saito, Y., Shiraishi, Y., &Yoshinaga, N. (2019). Cognitive-behavioral therapy for anxiety in dementia caregivers: A review of the foreign literature in English. Japanese Journal of Nursing and Health Sciences, 17(2), 28-36.

Suresh, M. R., Chung, K. K., Schiller, A. M., Holley, A. B., Howard, J. T., & Convertino, V. A. (2019). Unmasking the Hypovolemic Shock Continuum: The Compensatory Reserve. Journal of Intensive Care Medicine, 34(9), 696-706.

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