I know this is not the appropriate thread, but I'm not sure where else to ask.
I have a patient who is admitted for vaginal hysterectomy via spinal anaesthesia. RTW with IDC and PCA.
Obs on return to ward were
Respiration rate 30 per minute
• BP 90/50mmHg
• Pulse 130bpm
• Temperature 36.5C
• Pain 0/10
• Indwelling urinary catheter insitu with 10mls of urine output for the last hour
I'm going to argue that the BP and pulse are the result of bleeding during surgery and spinal anaesthesia. Low urine output + BP and pulse might possibly indicate dehyderation? I'm not sure what tachypnoea might indicate. Since spinal anaesthesia usually depress resp, is this an early sign of an infection? The patient has a history of depression and heavy smoking, would these have any major effect post op?
Probably too early for infection. I would say this patient likely has decreased volume related to blood loss (what was her estimated ebl? Does she have an active bleed) or hypovolemia (how much was she bolused during surgery ?) unless an infectious source was introduced during surgery, and the patient was cooled during surgery and still hadn't warmed up with an uncontrolled infectious source, sepsis is less likely. In this case, either through vasodilation or hypovolemia, preload is decreased ergo cardiac output is decreased, so the hr elevates to improve cardiac output.
If she has had mass blood loss or is currently bleeding, she has decreased oxygen carrying capacity therefore has to breathe faster to maintain oxygen requirements. Is she on supplemental o2? What was her rr before surgery? Does she have cope/asthma associated with the smoking? Smoking can impair both ventilation (asthma) or oxygenation. I also feel that smoking delays wound healing.
The decreased urine output feels like pre renal aki dt insufficient volume. But,is there a kink in her foley? How are her kidney function tests?
All this being said, what was her LOC? Her labs? Her perfusion? Was her vaginal bleeding heavy? Without a complete picture it is difficult to say what exactly is happening as all the assessment data ties together to form a picture.
Google the oxygen supply and demand framework. It's a great tool to use to try and figure out what is happening with a patient. I'm not expecting you to answer these questions online to protect patient confidentiality but are just cues I would look for on a patient like this.
Last edit by Castiela on Aug 13
: Reason: Spelling
I wasn't sure about the effects of the spinal anesthetic, what I found is probably more likely in this case.
"An epidural block interrupts both somatic and sympathetic nerve conduction; thus, cardiovascular changes, including hypotension and tachycardia, may occur. These cardiovascular changes can produce overwhelming complications if not promptly identified and treated. Respiratory compromise or failure can occur if the phrenic nerve or respiratory centers of the brain stem are inadvertently blocked. For this reason, epidural nerve blocks should be performed only by clinicians trained in airway management and resuscitation. Appropriate monitoring of vital signs is imperative, and resuscitation equipment must be readily available during the procedure" Chawla & Raghavendra, 2015
Last edit by Castiela on Aug 13
Thanks Castiel for your reply! This is from my uni assignment. That's all the information I got; no base line obs no spo2/O2 therapy, no info on bleeding, medication hx, LOC (she just returned from recovery so I assume she's at least rousable) , fluid balance, tanaestheics used; and based on that info I got to discuss the pathophysiology behind the post op "deterioration" and nursing management that needs to be implemented.
Nursing management that needs to be implemented: ask for a CBC, a lactic acid, BMP. Those are important pieces to the puzzle that will help figure out what is going on, otherwise you are pretty much just guessing around. Do something about that low BP and address the low UO quick (and yes, always check for kinks on the foley first, you'd be surprised;also: Do a bladder scan to determine whether the pt is not producing urine or if it is the foley that is not draining. besides a kink in the foley, another thing that could happen is a blood clot occluding the foley - who knows if there's any bleeding in the bladder, specially considering it was a hysterectomy). I'd be on the phone asking for orders and implementing them as quickly as possible.
The low urine output isn't likely dehydration the patient would have had IV fluids during surgery, it may be related to bladder injury during the surgery, check the catheter and bladder scan as RNbubu said, also check if urine is leaking from vagina.
Moved to Nursing Student Assistance
Hey there, nursing instructor here. Given the information this patient seems to be presenting with acute blood loss and hypovolemic shock compensation. The renal system may be shutting down to preserve fluid balance and enaure renal perfusion. The kidneys are telling the heart to increase the rate to keep up minimum perfusion. The Bp is concerning with the heart rate and tachypnea. Ecause these symptoms indicate intervention is needed before the patient can no longer compensate. Just my two cents. Post op, tachy, low bp, I think hypovolemic shock.
Thanks guys!! It all makes a lot more sense now!
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