CASE STUDY BASED ASSIGNMENT

Case Study Based Assignment

Case Study Based Assignment

QUESTION 1: From the case study above, select four (4) key pieces of assessment data that support a diagnosis of hypovolaemic shock. Explain how/why this data presents in hypovolaemic shock. [450 words]

Firstly, it states that the skin was cold, clammy with capillary refill. During hypovolaemic shock, blood is conserved for the vital organs, and blood flow to the skin is decreased. This makes the skin feel cold and clammy.

Secondly, Chest auscultation showed air entry equal, diminished in the bases, no adventitious sounds. In a patient with extensive myocardial damage, chest auscultation may reveal heart sounds consistent with valvular heart disease (regurgitation, outflow obstruction) or significant ventricular dysfunction (S3). Chest roentgenogram may detect dissecting ascending aortic aneurysm (widened mediastinum) or cardiomegaly. The chest should be auscultated for decreased breath sounds, because life-threatening hemorrhage can occur from myocardial, vessel, or lung laceration. (Banic 2003:74-85)

Thirdly, SpO2 which is 92% on room air. InSpectra StO2 changes dynamically with changes in a patient's perfusion status. This is clearly demonstrated in patients with hypovolemic shock; while InSpectra StO2 declines, SpO2 levels remain normal until lung function is compromised. InSpectra StO2 also responds to the interventions which improve perfusion status during resuscitation, while SpO2 may not change during fluid and blood product administration.

Lastly, HR 120/minute and regular shows that there is a diagnosis of hypovolaemic shock.Severe bleeding and hypovolemic shock causing hypotension are most often associated with tachycardia. In response to passive head-up tilt, five healthy men exhibited an increase in heart rate (HR) from 62 to 79 beats X min-1 and a gradual increase in the plasma concentration of aldosterone and protein. The increase in HR was followed by a decrease of 29 beats X min-1 (range 11-46) at the time when blood pressure decreased 38 mmHg (6-73). When tilted back to 0 degree, blood pressure immediately reversed while HR remained unchanged. (Taylor 2007:479-81)

Possible sources of blood loss are numerous, though the most common include splenic rupture, pelvic fracture (and subsequent vascular injury), and kidney and hepatic lacerations. A CT scan of the abdomen and pelvis is necessary to evaluate for these possibilities. Trauma patients also may have penetrating injuries that can go overlooked during the initial assessment, as a result of attention being shifted towards more obvious injuries, hemodynamic compromise, or patient agitation. Because of this potential, all trauma patients should be immediately stripped of clothing and every inch of their external body visually inspected. (Banic 2003:74-85)

Pressors are not effective in patients who are in hypovolemic shock, as the SVR is already severe elevated in response to the hypovolemia. Pressors, in this case, will probably worsen tissue perfusion, leading to lactic acidosis and end-organ damage. If a patient in hypovolemic shock fails to respond to initial fluids, they should receive more fluids and undergo more definitive treatment emergently (i.e. OR for traumatic injury, endoscopy for intraluminal lesions). (Mirvis 2008:1375-9)

It is concluded that although hypovolemic shock is most often associated with an increase in HR, the increase is ...