Beruflich Dokumente
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COLLEGE OF NURSING
City of Malolos
Hypovolemic Shock Probably 2O to Acute Blood Loss Probably 2O to Solid Organ Injury
2O to Penetrating Perforating Thoraabdominal Gun Shout Wound With G Lobe R: R
Flank / 6th Intercostals Space: L Deltoid / 2nd Intercostals Space: R Mandible R
Supraorbital.
INTRODUCTION
This case presentation is about a client in surgery ward of Jose B. Lingad Regional Memorial Hospital who was diagnosed of having Hypovolemic Shock
probably secondary to Acute Blood Loss probably secondary to solid organ injury secondary to penetrating perforating Thoraabdominal gun shot wound with G
We chose this case to become familiar with the applicable nursing interventions that can be applied for a patient with hypovolemic shock. This disease if not
cured and controlled will lead to a more serious disease. Hypovolemic shock may be complicated by impaired function of any organ since all organs depend on an
adequate blood supply and oxygen delivery for their functions. Therefore, an individual with hypovolemic shock may sustain a stroke, heart attack, liver failure,
Hypovolemic shock is an emergency condition in which severe blood and fluid loss makes the heart unable to pump enough blood to the body. Losing about
1/5 or more of the normal amount of blood in your body causes hypovolemic shock. Blood loss can be due to bleeding from cuts or other injury. The amount of
blood in your body may drop when you lose too many other body fluids, which can happen with diarrhea, vomiting, burns, and other conditions. The greater and
more rapid the blood loss, the more severe the shock symptoms.
The mortality rate in patients with hypovolemic shock is also high, with the cause of death generally being attributed to circulatory collapse due to severe
hemorrhage. Traumatic injury and blood loss induce irreversible circulatory shock and represent a major clinical problem, particularly in combat casualties.
Traumatic injury (often accompanied by severe blood loss) is the principal cause of death in patients aged 18-44 years. Traumatic injury accounts for millions
emergency room situations, millions of hospital admissions, and is estimated to cause 150,000 deaths each year. Although more effective prevention measures will
reduce the early deaths resulting from massive hemorrhage and central nervous system injury, the transition from reversible to irreversible hypovolemia, or
circulatory collapse, appears to play a major role in the majority of late deaths after trauma and blood loss.
OBJECTIVES
General Objectives
Student centered:
• To be able to acquire knowledge on how to manage and care for a patient with hypovolemic shock.
Patient centered:
Specific Objectives
Student centered:
• To be informed about the definition of hypovolemic shock and its clinical manifestations.
• To become familiar with the applicable nursing interventions that can be applied for a patient with hypovolemic shock.
• To gain knowledge on what drugs are given to a patient with hypovolemic shock and its therapeutic actions.
Patient centered:
NURSING ASSESSMENT
A. BIOGRAPHIC DATA
NAME : Mr. Jr
AGE : 30 Years of Age
GENDER : Male
CIVIL STATUS : Widower
POSITION IN THE FAMILY : Head of the Family
ADDRESS : Barangay Mining, Angeles City, Pampanga
DATE OF BIRTH : January 28, 1979
PLACE OF BIRTH : Angeles City, Pampanga
RELIGION : Roman Catholic
RACE : Asian
EDUCATIONAL ATTAINMENT : High School Graduate
HEALTH SOURCE : Prior hospitalization himself, presently his parents, some of his relatives and help coming from local
government.
DATE OF ADMISSION : September 02, 2009 (Tuesday) at 02:25am
FINAL DIAGNOSIS : Hypovolemic Shock Probably 2O to Acute Blood Loss Probably 2O to Solid Organ Injury 2O to Penetrating
Perforating Thoraabdominal Gun Shout Wound With G Lobe R: R Flank / 6th Intercostals Space: L Deltoid / 2nd
Intercostals Space: R Mandible R Supraorbital.
B. CHIEFT COMPLAINT
According to him, he was brought to Jose B. Lingad Regional Memorial Hospital (JBLRMH) last September 02, 2009 at exactly 02: 25am by a policeman. At that
time he was totally unconscious and has 7 reported gunshot wounds all over his body.
When we try to ask and seek for further explanation and clarification about what really happen to him, he verbalized “Bandang 1am ata yun, biglang may
pumasok sa bahay namin at pinaputukan kami ng asawa ko, tapos di kona alam, ang bilis ng pangyayai pagkagising ko nasa ospital na ako at nalaman kong patay na
pala ang asawa ko”. Then after that life threatening incident, his life was totally changed and become miserable not only physically but also mentally. And he cannot
According to him, he already has Rubeola, Mumps and Varicella when he was a child. He does not have any known food or drug allergies. There are no any major
injuries reported when he was a child in exception in some minor cases like falling in a bicycle and stairs. And there is no any serious hospital confinement which is
Aurora and Eduardo. There is no any family history of DM, HPN, COPD,CVD, Malignant Neoplasm etc. in his family both mother and father side.
GENOGRAM
N N
/A /A
N
/A N
/A
N N
/A N
N
/A 63 /A
65
/A N
/A N
/A N
/A N
/A
45
47 39 36 32 30
42 40 37 34 31
LEGEND
- MALE - PATIENT
- FEMALE - HYPOVOLENIC SCHOCK
- ALIVE AND WELL - OSTEOARTHRITIS
N
- DECEASE /A - NOT AVAILABLE
FUNCTIONAL PRIOR HOSPITALIZATION DURING HOSPITALIZATION
HEALTH
PATTERN
HEALTH He really believed in herbal medication like Lagundi Leaves extract in treating cough When I ask him if he can follow what doctors & nurse advices him he verbalized
PERCEPTION & and Guava Leaves extract as an effective anti-microbial; he also go to faith healers like “Minsan oo, minsan naman hindi, kasi mahirap ang pera ngayon tapos di naman ako
HEALTH Manghihilot and Manawas as they call it in Kapampangan dialect as a primary source ang gumagastos sa pag-kaka ospital ko”
MANAGEMENT of remedies if they experience unserious medical problems, he is a light smoker and
PATTERN
drinking alcoholic beverages occasionally.
NUTRITIONAL
METABOLIC 3 DAYS FOOD RECALL 3 DAYS FOOD RECALL
PATTERN
BREAKFAST LUNCH DINNER BREAKFAST LUNCH DINNER BREAKFAST LUNCH DINNER BREAKFAST LUNCH DINNER
½
Aug. 30, Sept. - 2 slices - cup of - 1 cup DO fluid DO fluid DO fluid
N/A N/A N/A N/A N/A N/A of bread Rice as of Rice restriction restriction restriction
09 08, 09
estimate - 1 slice
d of fried - He - He - He
Aug. 31, - Bangus consumed consumed consumed
N/A N/A N/A N/A N/A N/A
09 Sinigang about 5 about 5 about 5
na Baboy cups of cups of cups of
Sept. - 3 cups - 3 to 4 - 3to 4 - 1 mug of -4 - 4 to 5 but only small small small
01, 09 of Rice cups of cups of Coffee(12 glasses of glasses of the soup mineral mineral mineral
- 2 fried Rice Rice 0 ml) water(1 water(1 is eaten water(1 water(1 water(1
Eggs - 1 serving -2 glass is glass is cup is cup is cup is
of Sinigang pieces around around equal to equal to equal to
na Bangus( of 110 ml as 110 ml as 3- 5ml) 3- 5ml) 3- 5ml)
consist of 2 Chicken estimated estimated every every every
slices of ) ) meal time meal time meal time
Bangus, Sept. - 1 cup - 1 cup of - 1 cup - Totally - Totally - Totally
the noodles Rice of Rice he he he
standard 09, 09
- 4 slice -1 consumed consumed consumed
Mangkok of Pork serving about one about one about one
cant of bottle of bottle of bottle of
handle at Tinolang C2 which C2 which C2 which
least 50- Manok is 1 Liter is 1 Liter is 1 Liter
1oo ml of ( consist
fluids & of 2
selected slices of
vegetables chicken)
) - 2 slices - 1 cup of N/A - 1 glass - 1 bottle N/A
Note: Some of these information are only estimated accordingly to what patient verbalized
Sept.10,
09 of Bread Rice of water(1 of C2 at
-1 (because glass is least 300 (because
serving our duty around ml) our duty
of is from 110 ml as is from
He is taking vitamin supplement, specifically Enervon C but not continuously, he eats Sinigang 7am- estimated 7am-3pm
F. GROWTH AND DEVELOPMENT
NAME: MR. JR. AGE: 30 YEARS OLD HOSPITAL: JOSE B. LINGAD REGIONAL MEMORIAL HOSPITAL DATE: SEPT. 10, 2009
THEORY ERIK ERIKSON SIGMUND FREUD JEAN PIAGET LAWRENCE JAMES FOWLER
THEORY OF THEORY OF THEORY OF KOHLBERG THEORY THEORY OF FAITH
PSYCHOSOCIAL PSYCHOSEXUAL COGNITIVE OF MORAL DEVELOPMENT
DEVELOPMENT DEVELOPMENT DEVELOPMENT DEVELOPMENT
Medical Management Date Ordered/Date General Description Indications/Purposes Client’s response to the
Treatment Performed/Date Changed. treatment
Jackson Pratt September 3, 2009 Once you are under anesthesia A Jackson Pratt drain allows None
your surgeon will make an excess fluid to be removed
incision in your skin. The end from the body. Fluid that
of the drain tubing will be collects inside the body after
placed into the area where fluid surgery or injury can increase
has collected. (If you are the chance of infection or other
having surgery, the drain tubing complications. The drains are
will be placed at the end of placed routinely after some
your surgical procedure.) The kinds of surgery if large
other end of the tubing will be amounts of drainage are
connected to the squeeze bulb. expected.
The surgeon will remove the
stopper from the bulb, squeeze
it to create suction inside the
drain system, and replace the
stopper. This suction will pull
the unwanted fluid out of your
body. The skin is closed over
the drain.
Dextrose 5% water September 4, 2009 1. Provides calories for some This medication is a solution None
metabolic needs. Each 100 mL given by vein (through an IV).
provides 5 gm of Dextrose. It is used to supply water and
Depending on the presence of calories to the body. It is also
insulin, glucose enters cells and used as a mixing solution
is broken down to pyruvate. (diluents) for other IV
With adequate oxygen, it enters medications. Dextrose is a
the Krebs’s cycle in the natural sugar found in the body
mitochondria and is converted and serves as a major energy
into energy (A.T.P.), CO2 and source. When used as an energy
H2O. The brain and gonads do source, dextrose allows the
not require insulin for glucose body to preserve its muscle
metabolism. mass.
2. Supplies body water for
hydration.
3. Spares body protein by
providing carbohydrate for
metabolism.
4. Osmolarity of D5W is 252
mOsm/L. The fluid is isotonic
when in the container. After
administration, the dextrose is
quickly metabolized in the
body, leaving only water – a
hypotonic fluid.
5. The pH range is 3.5 – 6.5.
6. Capable of producing
diuresis depending on clinical
state of the patient.
Dextrose 5% Lactated Ringer’s September 7, 2009 Dextrose 5% Lactated Ringer's, It is indicated as a source of None
Solution USP administered water, electrolytes and calories
intravenously has value as a or as an alkalinizing agent.
source of water, electrolytes,
and calories. One liter has an
ionic concentration of 130 mEq
sodium, 4 mEq potassium, 2.7
mEq calcium, 109 mEq
chlorides and 28 mEq lactate.
The osmolarity is 525
mOsmol/L (calc). Normal
physiologic range is
approximately 280 to 310
mOsmol/L. Administration of
substantially hypertonic
solutions may cause vein
damage. The caloric content is
180 kcal/L.
Peritoneal Lavage September 3, 2009 It is performed when intra- a) Abdominal trauma and None
abdominal bleeding shock
(hemoperitoneum) usually
secondary to trauma is b) Multiple trauma with head
injury and decreased level of
suspected performed to identify
consciousness
abdominal injury.
c) Multiple trauma with
spinal cord injury
Thoracic Lavage September 3, 2009 Can be performed using an Provides satisfactory heat None
open or closed thoracostomy. transfer.
Thoracostomy and open
thoracic irrigation allow
“bathing” of the mediastinal
structure.
Peri-Hepatic Packing September 2, 2009 Peri-hepatic packing procedure, The purpose of this study was None
which is the basic damage to evaluate the efficacy of the
control technique for the perihepatic packing procedure
treatment of hepatic by comparing the outcomes of
hemorrhage, is one of the appropriately and
cornerstones of the surgical inappropriately performed
strategy for abdominal trauma. interventions.
Famotidine September 20 mg x 2 doses Histamine 2 Blockers. Famotidine is used to treat and prevent • Bleeding
7, 2009 IV every 12 ulcers in the stomach and intestines. It also • Confusion
hours. Famotidine is in a group of drugs treats conditions in which the stomach • Jaundice
September called histamine-2 blockers. It produces too much acid, such as Zollinger- • Weakness
8, 2009 works by decreasing the amount of Ellison syndrome. Famotidine also treats • Mood Changes
acid the stomach produces. gastroesophageal reflux disease (GERD) • Muscle Pain
September
and other conditions in which acid backs up • Headache
9, 2009
from the stomach into the esophagus,
causing heartburn.
September 9,
2009
Erythromycin September 7, OD Macrolide Antibiotics Macrolide antibiotics slow the growth of, or • Nausea
2009 sometimes kill, sensitive bacteria by • Stomach Pain
( eye ointment ) Erythromycin is used to treat many reducing the production of important • Loss of
September 8, different types of infections caused proteins needed by the bacteria to survive. Appetite
Ery- Pad 2009 by bacteria. It is also used to prevent • Chest Pain
bacterial endocarditis and attacks of
September 9, rheumatic fever.
2009
Cefazolin September 3, 1 gm IV every 8 Cephalosporin Antibiotic Cefazolin injection is used to treat many • Pain
2009 hours kinds of bacterial infections, including • Muscle
Anzef Cefazolin is in a group of drugs severe or life-threatening forms. Weakness
September 4, called cephalosporin antibiotics. It • Headache
2009 works by fighting bacteria in your
body.
Ketorolac September 3, 30 mg Non-Steroidal Anti- Inflammatory It used to treat moderate to severe pain. • Weakness
2009 Drugs. • Sensitive to
Toradol IV light.
September 4, Ketorolac is in a group of drugs • Headache
2009 called nonsteroidal anti- • Loss of
inflammatory drugs (NSAIDs). Appetite
Ketorolac works by reducing
hormones that cause inflammation
and pain in the body.
Tramadol September 3, Narcotic Drug. Tramadol is used to treat moderate to severe • Drowsiness
2009 pain. Tramadol extended-release is used to • Dizziness
Ultram Tramadol is a narcotic-like pain treat moderate to severe chronic pain when • Blurred Vision
September 4, reliever. treatment is needed around the clock. • Sleep Problems
2009
Elimination
Excess calcium is primarily excreted
renally while unabsorbed calcium is
excreted in the feces along with that
secreted in the bile and pancreatic
juice.
Diclofenac September 3, 75 mg x 2 doses Non-Steroidal Anti-Inflammatory Diclofenac is used to treat pain. • Weakness
Sodium 2009 IM every 12 Drugs. • Headache
hours. • Nausea
Voltaren September 4, It works by reducing hormones that
2009 cause inflammation and pain in the
body.
Celecoxib September Non-Steroidal Anti- Inflammatory Celebrex is prescribed for acute pain. • Abdominal
10, 2009 Drugs. Pain
Celebrex • Headache
It is a member of a new class of • Nausea
nonsteroidal anti-inflammatory
drugs (NSAIDs) called COX-2
inhibitors.
ACTIVITY
DEEP BREATHING September 2(prior to surgery) An exercise enhancing the An exercise advised to be The pt. was cooperative and
EXERCISE cardiac muscle and organs to performed by patients willing to perform the exercise
function, preparing the patient expected and scheduled for as he is aware of its
for surgery and preventing surgery importance
respiratory arrest
RANGE OF MOTION September 4 onwards (after ACTIVE ROM- this is done An exercise indicated for The pt is actively participative
EXERCISES surgery) by the pt, it increases and patients with musculoskeletal and says that he exercises
maintains muscle tone and impairment everyday.
joint mobility
SURGICAL MANAGEMENT
• OPERATING ROOM SPONGES, NEEDLES INSTRUMENT COUNT
Environment / Exercise
• Before discharge, assess the patient on the following:
ability to tolerate activity within the expected parameters
ability to ambulate
ability to perform activities of daily living
Treatment
• Advise the patient of increasing activity, avoiding prolonged bed rest and minimizing stress.
• Advise the family member to check patient regularly for evidence of complications such as skin breakdown or infections.
• Advise significant others to provide physiological support and understand expected emotional changes and coping stress.
Out-patient
• After a week of discharge, instruct the patient and family the need for follow up check up and adhere fully to the date, time and location of follow up
appointment.
Diet
• Encourage sodium-restricted diet. Mention some dietary source of sodium such as processed meats and fish, some dairy products, processed grains,
most canned goods, snack foods and some condiments and food additives.
• Encourage increase fluid intake.
• Encourage eating potassium rich foods for wound healing.
Spiritual
• Encourage strengthening faith to God, it can help to become emotionally and psychologically stable.
HEALTH TEACHINGS
of blood loss, and illness or injury causing the loss. In general, patients with milder degrees of shock tend to do better than those with more severe shock.
Hypovolemia can be recognized by elevated pulse, diminished blood pressure, and the absence of perfusion as assessed by skin signs (skin turning pale)
and/or capillary refill on forehead, lips and nail beds. Blood transfusions coupled with surgical repair are the definitive treatment for hypovolemia caused by
trauma.