Вы находитесь на странице: 1из 19
Saint Louis University School Of Nursing CASE PRESENTATION (HYPOVOLEMIC SHOCK) Submitted by: CAS-OY, Meck Malone C.
Saint Louis University School Of Nursing CASE PRESENTATION (HYPOVOLEMIC SHOCK) Submitted by: CAS-OY, Meck Malone C.

Saint Louis University School Of Nursing

CASE PRESENTATION (HYPOVOLEMIC SHOCK)

Submitted by:

CAS-OY, Meck Malone C. FERNANDO, Steward P. GURION, Elpidio Gregorio D. ALCANTARA, Michelle D. BASTA, Gilyann Joy C. DAYAO, Carla Nicole C. KARGANILLA, Jan Christy A. MAMUAD, Ivy Jenica S. NEBRES, Mary Joy D.

PALMERO, Chiki Rose B. RULLODA, Jimalowe R.

VALDREZ, Agatha Nicole C. BSN IV-B4

Submitted to:

Jertrude Biado, RN Instructor

August 2012

PATIENT’S PROFILE

Name: Patient Y

Age:

12 y/o

Sex: Female

Nationality: African-American

Final Diagnosis: Hyperglycemic Hyperosmolar Syndrome

History of Present Illness:

Four to five days prior to consultation, patient had been having upper-respiratory symptoms with diarrhea and vomiting for three days. Patient complained of being thirsty and had been supplementing her diet with milkshakes and smoothies. The night prior to consultation, patient awoke somewhat disoriented, which the parents assumed was a bad dream. On the day of consultation, patient became progressively weak, sleepy, and lethargic.

Family Health History:

There is a paternal family history of Type 1 Diabetes and no history of gestational diabetes. There is also a significant family history for obesity.

LABORATORY RESULTS

 

ABG

pH

7.12

Partially compensated metabolic

PCO2

50 mmHg

acidosis

HCO3

15 mM

PaO2

99 mmHg

 
 

CBC

WBC

 

14.6/ uL

High:

If the WBC count exceeds the

N=

N= 4.3 K/uL to 10 normal range, it would indicate that the

4.3 K/uL to 10

normal range, it would indicate that the

 

K/uL

person has an infection. This is because the leukocytes increase in number to fight off foreign substance

 

that has entered the system.

Hct

37 %

Within Normal range

 

N= 36.1 to 44.3%

Platelet

507, 000/ uL

N= 150,000 - 400,000

High: Can Cause:

platelets per microliter (mcL)

Excessive bleeding

Fainting or feeling light-headed

Hematoma (blood accumulating under the skin)

Infection (a slight risk any time the skin is broken)

Sodium

137 mM

Corrected Na=Measured Na +1.6 (glucose

(mg/dL)-100

=185 mM

N= 135 - 145

millimoles/liter (mmol/L)

Potassium

5.2 mM

N=

3.5 - 5.0

High: Increased potassium is known as hyperkalemia.

Potassium is normally

millimoles/liter (mmol/L

excreted by the kidneys, so disorders that decrease the function of the kidneys

can result in hyperkalemia. Certain medications may also predispose an individual to hyperkalemia.

> Increase levels occur with excessive IV administration, acute or chronic renal

failure, potassium – sparing diuretics, infection, and dehydration.

Chloride

102 mM

N= 98 - 108 mmol/L

Within normal range

Phosphorus

4.5 mg/dL

N= 2.5 – 4.5 mg/dL

Within normal range

Serum

2636

N= 70 and100 milligrams

Very high: higher most often means you have diabetes

glucose

mg/dL

per deciliter (mg/dL)

Osmolality

466

N= 275 to 295

 

mOsm/ L

milliosmoles per kilogram

High: may be due to:

Ethylene glycol poisoning

Methanol poisoning

Stroke or head trauma resulting in deficient ADH secretion

>When osmolality in the blood becomes high, the body releases

(ADH). This hormone causes your kidney to reabsorb water, which

results in more concentrated urine. The reabsorbed water dilutes the blood,

allowing the blood osmolality to fall back to normal.

BUN

77 mg/ dL

N= 6 – 23 mg/dL

 

High: Higher-than-normal levels may be due to:

MEDICATIONS

Brand Name: Intropin, Revimine Generic Name: Dopamine hydrochloride

Classification: Cahecholamine adrenergic, Inotropic, vasopressor MOA: Causes norepinephrine release (mainly on the dopaminergic receptors), leading to vasodilation of renal and mesenteric arteries. Also exerts intoropic effects on heart, which increases the heart rate, blood flow, myocardial contractility, and stroke volume.

Indication:

> Shock > hemodynamic imbalance > hypotension Contraindication:

> Hypersensitivity to drug or bisulfates > Tacchyarrythmias > Ventricular fibrillation > Pheochromocytoma Adverse reactions:

> CNS: headache > CV: palpitations, hypotension, angina, ECG chanes, tachycardia, vasoconstricvtion, arrhythmias > EENT: mydriasis > GI: nausea and vomiting

> Metabolic: azotemia, hyperglycemia > Respiratory: Dyspnea, asthma attacks > Skin: piloerection > Other: irritation at injection site, gangrene of extremities (with high doses for prolonged periods or in occlusive vascular disease)

Nursing Responsibilities:

> Monitor blood pressure, pulse, urinary output and pulmonary artery wedge pressure during infusion. > Inspect I.V site regularly for irritation. Avoid extravasation.

> Monitor color and temperature of extremities > Never stop infusion abruptly, because this may cause severe hypotension.

Brand Name: Vancocin Generic Name: Vancomycin hydrochloride

Classification: Tricyclic glycopeptide, Anti - infective MOA: Binds to bacterial cell wall, inhibiting cell – wall synthesis and causing secondary damage to bacterial membrane

> Severe, life – threatening infections caused by susceptible strains of methicillin –

resistant staphylococci, Staphylococcus epidermidis, Streptococcus viridians, Streptococcus bovis or Streptococcus faecalis.

> Endocarditis prophylaxis in penicillin – allergic patients at moderate risk who are scheduled for dental and other invasive procedures > Enterocolitis caused by Streptococcus aureus; antibiotic – related pseudomembranous diarrhea caused by Clostridium difficile

Contraindication:

> Hypersensitivity to drug Adverse reaction:

> CV: hypotension, cardiac arrest, vascular collapse > EENT:permanent hearing loss, ototoxicity, tinnitus >GI: nausea, vomiting, psedomembranous colitis

>GU: nephrotoxicity, severe uremia > Hematologic: eosinophilia, leukopenia, neutropenia > Respiratory: wheezing, dyspnea >Skin: red man” syndrome (nonallergic histamine reaction with rapid IV infusion), rash, urticaria, pruritus, necrosis >Other: chills, fever, thrombophlebitis at injection site, anaphylaxis Nursing Responsibility:

> Monitor closely for signs and symptoms of hypersensitivity reactions, including anaphylaxis.

> Assess BUN and creatinine levels in patients with unstable renal function. > Monitor urine output daily. > Stay alert for hearing loss > Check IV site often for phlebitis > Watch for “red man” syndrome, which can result from rapid infusion. Signs and symptoms include hypotension, pruritus, and maculopapular rash on face, neck, trunk and limbs. > Monitor CBC. Watch for signs and symptoms of blood dyscrasias. > Monitor respiratory status. Stay alert for wheezing and dyspnea.

Brand Name: Rocephin

Generic Name: Ceftriaxone Sodium Classification: Third generation cephalosporin, anti - infective MOA: Interferes with bacterial cell wall synthesis and division by binding to cell wall, causing cell death. Active against gram – negative and gram positive bacteria, with expanded activity against gram negative bacteria. Exhibits minimal immunosuppressant activity.

Indication:

> infection of respiratory system, bone, joints and skin; septicaemia

Contraindication: hypersensitivity to cephalosporins or penicillins Adverse reaction:

> CNS: headache, confusion, hemiparesis, lethargy, paresthesia, syncope, seizures > CV: hypotension, palpitations, chest pain, vasodilation > EENT: hearing loss > GI: nausea, vomiting, diarrhea, abdominal cramps, oral candidiasis, pseudomembranous colitis > GU: vaginal candidiasis, nephrotoxicity > Hematologic: lymphocytosis, eosinophilia, bleeding tendency, haemolytic anemia, hypoprothrombinemia, neutropenia, thrombocytopenia, agranolocytosis, bone marrow depression > Hepatic: hepatic failure, hepatomegaly > Musculoskeletal: arthralgia > Respiratory: dyspnea > Skin: urticaria, maculopapular rash, erythematous rash > Others: chills, fever, superinfection, anaphylaxis, serum sickness

Nursing Responsibility:

> Monitor foe extreme confusion, tonic – clonic seizures, and mild hemiparesis > Assess CBC and kidney, liver function test > Monitor for signs and symptoms of superinfection and other serious adverse reactions > watch out for a reduced urine output, persistent diarrhea, bruising or bleeding.

Brand Name: Lovenox Generic Name: Enoxaparin Sodium

Classification: Low molecular weight heparin, Anticoagulant MOA: inhibits thrombus and clot formation by blocking factor Xa and factor IIa. This inhibition accelerates formation of antithrombin III – thrombin complex (a coagulation inhibitor) thereby deactivating thrombin and preventing conversion of fibrinogen to fibrin. Indication: Prevention of pulmonary embolism and deep vein thrombosis , prevention of ischemic complications of nstable angina or non – Q wave myocardial infarction Contraindication: hypersensitivity to drug, heparin, sulphites, benxyl alcohol or pork products, thrombocytopenia, active major bleeding

Adverse reaction:

CNS: dizziness, headache, insomnia, confusion, cerebrovascular accident CV: edema, chest pain, atrial fibrillation, heart failure GI: nausea, vomiting, constipation GU: urinary retention Hematologic: anemia, bleeding tendency, thrombocytopenia, hemorrhage Metabolic: hyperkalemia Skin: bruising, pruritic rash, urticaria Other: fever, pain, irritation, erythema Nursing responsibility:

> Monitor CBC and platelet counts. Watch out for signs and symptoms of bleeding or bruising. > Monitor intake and output. Watch out for fluid retention and edema.

> Assess for irregular heartbeat, unusual bleeding, rash or hives.

Drug: Potassium Chloride Classification: Mineral, electrolyte replacement, nutritional supplement

MOA: Maintains acid – base balance, isotonicity, and electrophysiologic balance throughout body tissues; crucial to nerve impulse transmission and contraction of

cardiac, skeletal, and smooth muscle. Also essential for normal renal fucnton and carbohydrate metabolism.

Indication:

> to prevent potassium depletion > Potassium depletion; diabetic ketoacedosis; metabolic alkalosis; arrhythmias, periodic paralysis attacks, hyperadrenocortism; primary aldosteronism, healing phase

of sclads or burns, over medication with adrenocorticoids, testosterone or corticotrophin

Contraindication:

> hypersensitivity to drug > acute dehydration > heat cramps > hyperkalemia > severe renal impairment > severe haemolytic reaction > severe tissue trauma > esophageal compression caused by enlarged left atrium

> concurrent use of potassium – sparing diuretics, angiotensin – enzyme converting inhibitors, or salt substitute containing potassium

Adverse reaction:

> CNS: confusion, unusual fatigue, restlessness, asthenia, flaccid paralysis, paresthesia, absent reflexes > CV: ECG changes, hypotension, arrhythmias, heart block, cardiac arrest > GI: nausea, vomiting diarrhea, abdominal discomfort, flatulence > Metabolic: hyperkalemia > Musculoskeletal: weakness and heaviness of legs > Respiratory: repiratory paralysis > Other: irritation at IV site Nursing Responsibility:

> Monitor renal function, fluid intake and output, potassium, creatinine and blood urea nitrogen levels. > Asses vital signs and ECG. Stay alert for arrhythmias. > Monitor neurologic status. Watch for neurologic complications.

> Assess for the presence of adverse reactions. > Should be used cautiously to patient with severe renal impairment because of hyperkalemia.

Drug: Sodium Acetate Classification: electrolyte

MOA : Sodium plays an important role in controlling the total body water and its distribution. Sodium is the main cation in the extracellular fluid and comprises >90% of total cations. The acetate component is an alternate source of bicarbonate by metabolic conversion in the liver.

Indication: an alternative to sodium

chloride to provide sodium ion (Na + )

Adverse effects: gastric distension, flatulence; phlebitis; pulmonary oedema; congestive conditions; dilution of serum electrolytes, over-hydration, hypokalaemia, metabolic alkalosis, hypocalcaemia;

Nursing responsibility:

> Solutions containing acetate ions should be used with great care in patients with metabolic or respiratory alkalosis > Acetate should be administered with great care in those conditions in which there is an increased level or an impaired utilization of this ion, such as severe hepatic insufficiency. >Do not administer unless solution is clear and seal is intact;

Drug: Potassium phosphate Classification: Mineral, electrolyte supplement

MOA: Phosphorus is involved in many biochemical functions in the body and significant metabolic and enzyme reactions in almost all organs and tissues; it exerts a modifying influence on the steady state of calcium levels, a buffering effect on acid- base equilibrium, and a primary role in the renal excretion of hydrogen ion. Potassium is the principal intracellular cation; it helps transport dextrose across the cell membrane and contributes to normal renal function.

Indication:

> for addition to large volume intravenous fluids to prevent or correct hypophosphatemia

Contraindication:

> hyperkalemia

>hyperphosphatemia

> hypercalcemia

Adverse reactions:

> paresthesia of the extremities, flaccid paralysis, listleness, mental confusion, weakness and heaviness of the legs, hypotension, cardiac arrhythmias, heartblock, electrocardiographic abnormalities, hypocalcemic tetany

Nursing Responsibility:

> Monitor serum electrolyte levels particularly Ca levels, ECG and renal function during the course of therapy

Drug: Insulin Classification: Pancreatic hormone, hypoglycaemic MOA: Promotes glucose transport, which stimulates carbohydrate metabolism in skeletal and cardiac muscle and adipose tissue. Also promotes phosphorylation of

glucose in liver, where it’s converted to glycogen. Directly affects fat and protein metabolism, stimulates protein synthesis, inhibits release of free fatty acids and indirectly decreases phosphate and potassium.

Indication:

> Type 1 and type 2 diabetes mellitus unresponsive to diet and oral hypoglycemics

> Diabetic ketoacidosis Contraindication:

> Hypersensitivity to drug or its components > hypoglycaemia Adverse reactions:

> Metabolic: hypokalemia, sodium retention, hypoglycaemia, rebound hyperglycemia > Skin: urticaria, rash, pruritus

> Other: edema, lipodystrophy, lipohypertrophy; erythema, stinging or warmth at injection site, anaphylaxis

Nursing Responsibility:

> Monitor glucose level frequently to assess drug efficacy > Watch blod glucose level closely f patient is converting from one insulin type to another or is under unusual stress > Monitor for signs and symptoms of hypoglycaemia. > Monitor for glycosuria > Evaluate kidney and liver function test results

PRIORITIZED PROBLEMS WITH JUSTIFICATION

PROBLEMS

PRIORITIZATION

  • 1. Deficient fluid volume related to active fluid volume loss

The patient experienced hypovolemic shock and had worsening hyperglycemia that hastens osmotic dieresis leading to dehydration, so they had to intervene by fluid resuscitation, the patient received 20L of intravenous fluids within the 36 hours of hospitalization, and this is because the patient is severely dehydrated. This is classified under the circulation of ABC in emergency assessment. An article by Robin R Hemphill, MD, MPH; Chief Editor:

Erik D Schraga, MD entitled hypovolemic shock

stated that when glycemia reaches approximately 180 mg/dL, proximal tubular transport of glucose

from the tubular lumen into the renal interstitium becomes saturated, and further glucose reabsorption is no longer possible. The glucose that remains in the renal tubules continues to travel into the distal nephron and, eventually, the urine, carrying water and electrolytes with it. Osmotic diuresis then results, the loss of water results in further hyperglycemia and loss of circulating volume. Hyperglycemia and the rise in the plasma protein concentration cause a hyperosmolar state. The hyperosmolarity of the plasma triggers release of antidiuretic hormone, which ameliorates renal water loss. In the presence of HHS, if the renal water loss is not compensated for by oral water intake, dehydration leads to hypovolemia. Hypovolemia, in turn, leads to hypotension, which is presented in the case and hypotension results in impaired tissue perfusion. Without this problem being not able to

be resolved, then it will lead now to the next problems below, hence our 1st prioritization.

  • 2. The patient had a BP of 79/37 which is below normal value and also indicates hypotension. It is caused by hypovolemia. This is also can

Decreased

cardiac output

be classified as circulation under the concept of ABC assessment because it deals with the blood circulating through the heart which is

related to

decreased but it can also affect the breathing of the patient. A study by L. I. G. WORTHLEY entitled Shock: A Review of Pathophysiology

hypovolemia

and Management. Part I stated that there would be a neural or immediate response that happens when there is low circulating blood volume. The right atrial and left atrial pressures fall, activating low pressure receptors in the atria and walls of the pulmonary arteries, great veins and ventricles. With further intravascular blood loss, the reduction in venous return causes a decrease in cardiac output and blood pressure. In addition, severe hypotension (e.g. MAP of 50 mmHg or less) activates chemoreceptor receptors of the carotid and aortic bodies; and at a MAP of 40 mmHg or less, a central nervous system ischaemic response occurs. These signals are transmitted to the vasomotor centre in the medulla and pons, which sends efferent impulses via the sympathetic and vagus nerves to increase the heart rate, myocardial contractility and peripheral arteriolar and venous tone. If the problem is not resolved, it would lead to another problem which is ineffective tissue perfusion, hence the 2 nd prioritization.

  • 3. Ineffective tissue perfusion related to blood loss and hypotension

This problem is caused by the decreased cardiac output. This fall in the circulation category of the ABC emergency assessment. Because of the decreased blood volume that causes hypotension and also decreased cardiac output, the perfusion is not enough for the vital organ like the heart would work/function. An article by Lynn Duane, MSN, RN, TCHP Program Manager entitled Types of Shock presents the straight forward pathophysiologic process of hypovolemic shock where in blood and/or fluids that have left the body, will cause a decreased amount of volume in the blood vessels. Venous return is decreased because of the lack of fluid in the vascular space, causing decreased ventricular filling. The ventricles do not have as much blood as normal to pump out, so the stroke volume is decreased. The heart rate will increase to compensate for the diminished stroke volume and resulting poor cardiac output and blood pressure. Eventually, if the fluid or blood loss continues, the heart rate will not be able to compensate for the decreased stroke volume resulting to inadequate tissue perfusion, hence our 3 rd prioritization.

  • 4. Unstable blood

The patient glucose level is 2636 which is elevated above normal value.It falls under circulation in ABC assessment concept, because of

glucose level

persistent dehydration cause by massive fluid loss; it would now cause the blood glucose to rise. A reading from a book by Ellie Whitney,

increased

Linda Kelly DeBruyne, Kathryn Pinna, Sharon Rady Rolfes entitled Nutrition for Health and Health Care under Hyperosmolar

resistance to

Hyperglycemic Syndrome in Type 2 diabetes, it states there that HHS is a condition of severe hyperglycemia and dehydration that

insulin

develops in the absence of significant ketosis. The profound dehydration that eventually develops exacerbates the rise in blood sugar levels, which often exceed 600 mg/dL and may climb above 1000 mg/dL. Blood plasma becomes so hyperosmolar as to cause neurological abnormalities such as abnormal reflexes, motor impairements and seizures. The hyperosmolar hyperglycemic syndrome is sometimes the first sign of type 2 diabetes in older persons. If the problem will not be resolved it may lead to another problem which is impaired renal function, Hence prioritizing it the 4 th .

  • 5. Impaired renal

Because of the patient’s unstable blood glucose, there would be an alteration of the liver to function properly. In ABC emergency

function related to

assessment, this problem would fall to circulation because it has something also to do with the decreased blood volume that is going

abnormal renal

through the kidneys which can impair the renal perfusion thus affecting the renal function. An article entitled Renal Disease in Type 2

perfusion

Diabetes Media Fact Sheet states that the increase level of blood glucose can damage the kidney’s filters. This leaves people with type 2 DM at risk of developing renal impairment. When the kidneys are damaged, the protein albumin leaks out of the kidneys into the urine. The problem identified is the 5 th prioritization.

  • 6. Disturbed thought processes related

The patient has a GCS of 7, Lethargy and Disorientedness caused by decreased tissue perfusion. Under the ABC emergency

to decreased cerebral perfusion

assessment, it can fall under the circulation because it has something to do with the decreased blood circulating to the brain .A study by Phil Zeitler , Andrea Haqq, Arlan Rosenbloom ,Nicole Glaser entitled Hyperglycemic Hyperosmolar Syndrome in Children:

Pathophysiologic Considerations and Suggested Guidelines for Treatment states that the effect of HHS on the brain may differ from that seen in DKA and this difference must also be considered in planning treatment. Studies of chronic hypertonicity suggest that brain cells produce “idiogenic osmoles”, osmotically active substances that preserve intracellular volume by increasing intracellular osmolality. Patients are thought to be at risk for cerebral edema if the rate of decline in serum osmolality exceeds the rate at which brain cells can eliminate osmotically active particles. Therefore, in theory, children with HHS, who experience prolonged, persistent hypertonicity should be at greater risk for cerebral edema via this mechanism than those with DKA, in whom hypertonicity is less severe and of shorter duration. Recent data suggest that cerebral vasoconstriction due to hypocapnia may be important in the pathogenesis of DKA-related cerebral edema. Diminished circulatory volume combined with cerebral vasoconstriction may lead to cerebral hypo perfusion with edema occurring during reperfusion. So, because of the hypoperfusion in the brain there can be an effect in altering the mental health status of the patient. If this problem cannot be resolved, it can lead to another problem which is the risk for injury hence prioritized as the 6 th .

  • 7. for

Risk

injury

This problems falls under the circulation of ABC assessment concept because of the decreased systemic circulation in the brain, there is

related to altered

also a decreased in perfusion which can present manifestations of altered mental health status like disorientedness and lethargy. This a

level

of

potential problem that has not yet occurred, but interventions are directed at prevention, hence the last prioritization

consciousness

NURSING CARE PLANS

 

EXPLANATION

       

ASSESSMENT

OF THE

PROBLEM

GOALS AND

OBJECTIVES

 

INTERVENTIONS

   

RATIONALE

EVALUATIO

N

P#

Hypovolemic

 

STO>

Dx

   

Shock

 

Within 8 hours

Assess

patient’s

Increased respiratory rate and use of accessory muscles

S> “

nursing intervention the patient will maintain fluid volume at a

respirations by observing respiratory rate and depth and use of accessory muscles.

may be seen in patients with hypoxia. Factors which increase respiratory rate are the following: low ph (acidosis)-via peripheral, high PaCo2 (Hypercapnea)- via (mainly) central, peripheral, low PaO2

O

functional level as

 

(hypoxemia)-via peripheral, raised temperature

With a chief

evidenced by:

(hyperthermia)- via peripheral, skin, pain, severe

complaint of altered mental status

  • a. moist mucous membrane.

hypotension-via peripheral, arterial baroreceptor, some chemical and irritants, exercise- via joint/ muscle receptor, voluntary control (to limited extent),

With a history

  • b. good skin turgor.

Increased elastic recoil and/or lower airway resistance.

of

upper

  • c. prompt capillary

  • d. adequate urine

Hypoxia is a pathological condition in which the body

respiratory

symptoms 4-5

refill.

as whole (generalized hypoxia) or a region of the body (tissue hypoxia) is deprived of adequate oxygen supply.

days ago

output at least

In the latter, the oxygen concentration within the

With

history

30 cc per hour.

arterial blood is abnormally low. It is possible to

of diarrhea

experience hypoxia and have low oxygen content but

and vomiting

Within 8 hours of nursing intervention

maintain high oxygen partial pressure. Hypoxia also

for three days Supplementin

the patient will be able to

occurs in healthy individuals when breathing mixtures of gases with low oxygen content.

g her diet with

Observe

patient

for

 

milkshakes and smoothies

  • a. increase GCS from 7 to 9.

restlessness, agitation, confusion and (late stages)

Changes in behavior and mental status can be early signs of impaired gas exchange which will result from

hypoxia, which is the lack of oxygen in the tissues.

when she was thirsty Progressively

LTO

lethargy.

decreased cardiac output. The interference of gas exchange occurs when the function of a number of different organs and tissues is impaired. The most

weak

and

within 72 hours of

 

sleepy

nursing

common form of impairment to gas exchange is

With

lethargy

 

interventions, the

   

Hypoxia can be caused by hypoventilation, diffusion

 

noted

 

patient will be able

impairment, shunt, and or ventilation-perfusion (the

Mild

to

rate of ventilation to CO2 production) inequality.

polydipsia

a.

Achieve a

Hypoventilation is the reduced alveolar ventilation in

noted

 

normal sinus

comparison to the metabolic CO2 production in which

Some nocturia

rhythm from

the PCO2 levels increase above normal. It is caused by

over

the

past

sinus

Assess

for

mental

status

disease in the lung or deficits in the respiratory control

few nights

tachycardia.

changes.

 

pathway from the medulla to the chemoreceptors.

With

a

   

Increasing

lethargy,

confusion,

restlessness

and/or

paternal history of type 1 DM With significant family history of obesity

a

irritability can be early signs of cerebral hypoxia from decreased cardiac output. Cerebral hypoxia occurs when there is not enough oxygen getting to the brain. The brain needs a constant supply of oxygen and nutrients to function. Cerebral hypoxia may be caused by: cardiac arrest, cardiac arrhythmia and very low blood pressure. Brain cells are extremely sensitive to a

With

a

GCS

lack of oxygen. Some brain cells start dying less than 5

of 7

minutes after their oxygen supply disappears. As a

Vital

signs:

Monitor

urinary

output.

result, brain hypoxia can rapidly cause severe brain

PR: 159 bpm,

Measure or estimate fluid

damage or death.

RR:

20 cpm,

losses

from

all

sources

 

T:

104.4°F

such

as

gastric

losses,

Fluid replacement needs are based on correction of

(40.2°C),

79/37

BP:

wound

drainage, and

diaphoresis.

current deficits and ongoing losses. A decreased urinary output may indicate insufficient renal perfusion or

With

weight

   

hypovolemia, or polyuria can be present, requiring

of

65

kg and

 

more aggressive fluid replacement. A large decrease in

BMI

was

26

kg/m²

(80 th

urine output may be a sign of a serious, or even life- threatening, condition. However, urine output can

percentile

for

usually be restored if you get medical treatment right

age)

Observe

changes

in

 

away. Some causes of decreased urine output may be

Rapid glucose

patient

for

skin color,

blood loss, dehydration and severe infection.

test

read

   
 

moisture, temperature and

 

>750mg/dl

     

capillary refill time.

Pallor or cyanosis, cool moist skin and slow capillary

 

Pupils

were

   

refill time

may

be

present

from peripheral

equal

and

vasoconstriction and decreased oxygen saturation.

responsive

to

Some of the possible common medical causes of

light

Assess peripheral pulses.

decreased oxygen concentration may include:

Mucus

 

hypoventilation. Peripheral vasoconstriction may be

membranes

caused by hypovolemic shock.

were dry

Neck

was

Weak

thread,

peripheral

pulses

may reflect

supple

with

hypotension, vasoconstriction, shunting and venous

no

jugular

congestion. Hypotension is pressure so low it causes

venous

symptoms or signs due to the low flow of blood

distension and

through the arteries and veins. When the flow of blood

notable

for

 

TX:

is too low to deliver enough oxygen and nutrients to

acanthosis

Turn

frequently, gently

vital organs such as the brain, heart, and kidney, the

nigricans

massage skin, and protect

organs do not function normally and may be

Decreased

temporarily or permanently damaged.

breath sounds

bony prominences.

on

the

right

 

Tissues are susceptible to breakdown because of

base

with

vasoconstriction and increased fragility (Doenges et al,

nasal

some flaring but no significant respiratory distress Cardiac

2006). Deficient fluid volume decreases tissue oxygenation, which makes the skin more vulnerable to breakdown (NA, 2009). Positioning the patient can also increase perfusion throughout the body; place the patient in a modified Trendelenburg's position to facilitate venous

examination

 

Provide safety precautions

return and to prevent excessive abdominal viscera shift

was consistent

such as use of side rails

and restriction of the diaphragm that occurs with the

with

sinus

 

head-down position (NA, 2011).

tachycardia

 

Collaborative:

 

and

no

Administer IV solutions as

Decreased

cerebral

perfusion

frequently

results

in

murmurs

indicated.

changes

in

mentation/

altered

thought

processes,

Pedal

pulses

     

- Isotonic

 

requiring protective measures to prevent client injury

 

were

 

(Doenges et al, 2006).

minimally

 

palpable

 

Abdomen was

Isotonic solutions cause intravascular expansion and

obese,

soft

possibly some interstitial edema but no water shifts into

and

non-

or out of cells (Na, 2000). It helps restore intravascular

distended,

volume; this will decrease counterregulatory hormones

with

no

and lower blood glucose, which should augment insulin

hepatospleno

sensitivity. The initial fluid of choice is isotonic saline

megaly

 

(0.9% NaCl), even in HHS patients or DKA patients

Striae

were

Administer

supplemental

with marked hypertonicity, particularly in patients with

present on the flanks

oxygen as indicated

evidence of severe sodium deficits manifested by hypotension, tachycardia, and oliguria. Isotonic saline

ABG:

ph:

 

is hypotonic relative to the patient's extracellular fluid

7.12,

PCO2:

and remains restricted to the extracellular fluid

500mmHg,

compartment (Kitabchi et al, 2001).

HCO3:

 

15mM;

Since low oxygen levels in blood (hypoxemia) is

PaO2:99mmH

among the common signs and symptoms of circulatory

g.

Administer

Dopamine

shock, doctors usually recommend oxygen therapy to

CBC:

WBC-

Hydrochloride as indicated

the treatment of circulatory shock. Oxygen

14.6/uL,

a

 

supplementation is mandatory in order to lower risking

Hct: 37% and Plt:

potential complications that may result from hypoxemia (NA, 2011). It is also necessary to provide

507,000/uL

oxygen support to impending respiratory distress

Electrolytes:

 

Edx

during shock.

Na:

137mM,

Encourage patient to drink

 

K:

5.2

mM.

It

causes norepinephrine release (mainly on the

Cl:

102 mM,

increase fluid intake at least 8 glasses per day as

dopaminergic receptors), leading to vasodilation of

Cl:

102mM,

tolerated.

renal and mesenteric arteries. Also exerts intoropic

Phosphorus:

 

effects on heart, which increases the heart rate, blood

4.5 mg.dl flow, myocardial contractility, and stroke volume.  Serum glucose:  2636mg/dL, Osmolality:46 6 mOsm/L;
4.5 mg.dl
flow, myocardial contractility, and stroke volume.
Serum
glucose:
2636mg/dL,
Osmolality:46
6
mOsm/L;
BUN
77mg/dl;
Creatinine:
4.08mg/dl,
Encourage to eat food high
in fluid content such as
watermelon, potato,
pineapple, strawberries
and orange.
Troponin
I:
0.268
ng/ml;
One reason might be that your blood volume is too low
causing low blood pressure. Low blood pressure can
make you feel light-headed and is dangerous because
you need your blood to be able to deliver oxygen to
your brain and the rest of your body. You can increase
your blood volume and hence your blood pressure by
increasing your fluid intake. Also, when you are
dehydrated your body can become deficient in certain
things such as sodium, potassium,and other
electrolytes.
Lactic
acid:
7.6mM,
Pineapple, strawberries and oranges contain some of
amylase
112
the
highest
percentage
of
water.
U/L,
Hgb
A1C- 11.5%;
With
Urinalysis
result
of:
Instructed the SO to report
any changes in skin color,
moisture, temperature of
the client.
These will relieves thirst and discomfort of dry mucous
membranes and augments parenteral replacement.
Water balance is achieved in the body by ensuring that
the amount of water consumed in food and drink (and
3+glucose and
trace ketones
A1> Deficient
generated by metabolism) equals the amount of water
excreted. The consumption side is regulated by
behavioral mechanisms, including thirst and salt
cravings.
fluid
volume
 Pallor or cyanosis, cool moist skin and slow capillary
related
to
refill time
may
be
present
from peripheral
active
fluid
loss
A2>
vasoconstriction and decreased oxygen saturation.
Some of the possible common medical causes of
decreased oxygen concentration may include:
Decreased
cardiac output
hypoventilation. Peripheral vasoconstriction may be
caused by hypovolemic shock.
related
to
decreased myocardial contractility A3>Ineffectiv e tissue perfusion related to decrease in the cellular components required for
decreased
myocardial
contractility
A3>Ineffectiv
e
tissue
perfusion
related
to
decrease in
the cellular
components
required for
the delivery of
oxygen to the
cells

REFERENCES

Assessing hydration status. (2011). Measuring and managing fluid balance. Retrieved from http://www.nursingtimes.net/nursing-practice/clinical-specialisms/nutrition/measuring-

David, Z., David, R. E. & Dugdale, D. C. III. (2011). Platelet count. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/003647.htm

Deficient Fluid Volume. (2011) Deficient fluid volume| Nursing Care Plan (NCP) Hypovolemia. Retrieved from http://www.enurse-careplan.com/2011/09/deficient-fluid-volume- nursing-care.html

Duanne, L. (n. d.) Types of shock. Retrieved from http://mnhealthandmedical.com/tchp_shock_series_part_2.pdf

Dugdale, D. C. III, Miller, S. & Zieve, D. (2011). Urine output-decreased. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/003147.htm

Each commercial laboratory. (n. d.) Normal Laboratory Values. Retrieved from http://www.aids.org/topics/normal-lab-values/

Gas Exchange. (n.d.) Gas exchange. Retrieved from http://www.enotes.com/gas-exchange-reference/gas-exchange

Hemphill, R. R. (2012). Hyperosmolar hyperglycemic State. Retrieved from http://emedicine.medscape.com/article/1914705-overview#a0104

Hoch, D. B. & Zieve, D. (2010). Cerebral hypoxia. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/001435.htm

Hopkins, T. (2005). Lab Notes: Guide to Lab and Diagnostic Tests. F. A. Davis Company, Philadelphia, Pennsylvania

Ineffective

Tissue

Perfusion.

(2012).

Ineffective

tissue

perfusion

nursing

diagnosis

and

interventions-Anemia.

Retrieved

from

Kitabchi, A. E., Umpierrez, G.E., Murphy, M. B., Barrett, E. J., Kreisberg, R. A., Malone, J. I. & Wall, B. M. ( 2001). Management of Hyperglycemic Crises in Patients with Diabetes. Diabetes Care, 24(1), 131-153. DOI: 10.2337

Lemone, P., & Burke, K.M. (2008). Medical Surgical nursing: Critical thinking in client care. (4th ed.). Upper Saddle River, NJ: Pearson Education Inc.

Marks, J. W. (2010). Low Blood Pressure. Retrieved from http://www.medicinenet.com/low_blood_pressure/article.htm

Normal Laboratory Values. (n. d.) Normal laboratory values. Retrieved from http://www.mtworld.com/tools_resources/lab_values.html

Peripheral Vasoconstriction. (2012). Peripheral vasoconstriction. Retrieved from http://www.rightdiagnosis.com/sym/peripheral_vasoconstriction.htm

Perrin, K.O. (2010). Understanding the Essentials of Critical Care Nursing. Retrieved from http://wps.prenhall.com

Renal

Impairment.

(2010).

Renal

disease

in

type

2

diabetes.

Retrieved

from

Respiratory Rate. (2005). Respiratory rate. Retrieved from http://www.ld99.com/reference/old/text/2878909-223.html

Schull, P.D (2008). Nursing Spectrum Drug Handbook. The Mcgraw – hill Companies. United States of America

Shock is a. (2007). Management of shock. Retrieved from http://www.nurse-ocha.com/2007/07/management-of-shock.html

Smeltzer, S. C. & Bare, B. G. (2010). Brunner & Suddart’s Textbook of Medical-Surgical Nursing. (12 th ed.). Philadelphia: Lippincott Williams and Wilkins.

The circulatory system. (2011). The use of oxygen therapy in hypovolemic shock. Retrieved from http://domvp.com/tag/the-use-of-oxygen-therapy-in-hypovolemic-shock/

The human body. (2012). List of water-rich foods. Retrieved from http://www.ehow.com/list_5910953_list-water_rich-foods.html

What is Hypoxia. (n.d.). What is Hypoxia. Retrieved from http://www.news-medical.net/health/What-is-Hypoxia.aspx

Whitney, E., DeBruyne, L. K., Pinna, K. & Rolfes, S. R. (2010). Nutrition for health and health care. Retrieved from http://books.google.com.ph

Worthley,

L.

I.

G.

(2000).

Shock:

A

review

of

pathophysiology

and

management.

Part

I.

Critical

Care

and

Resuscitation

2,

55-65.

Retrieved

from