Cardiovascular, fluid balance, hyper + hypovolemia assessment and monitoring - PACU

Question 1

malignant hypertension / hypertensive emergency

Answer 1

Severely elevated BP.
- blurry vision
- change in mental status
- chest pain
- cough
- headache
- nausea or vomiting
- Numbness in the arms, legs, face

Question 2

Postoperative hypertension nursing intervention

Answer 2

• Notify anaesthesia if pt has systolic BP >180mmHg, diastolic >105mmHg in two or more readings.
• Identify the cause of HTN and manage
• Give 02 and monitor vital signs
• persistently high, attach ECG and monitor for rhythm changes
• monitor for signs of malignant hypertension

Question 3

Postoperative hypotension - nursing management

Answer 3

• Identify cause
• Hypovolemia - fluid bolus may be indicated
• elevate pt leg, don’t tilt the bed
• increase 02 sat
• agitation, chest pain, discomfort - ECG to check for rhythm changes
• If pt has good perfusion, and their BP is within 15% of baseline reading, there is no need for intervention however strict monitoring is required.

Question 4

types of fluid solutions

Answer 4

• Crystalloids
• Colloids
• Blood/blood products

Question 5

Classifying fluids

Answer 5

• isotonic
• hypertonic
• hypotonic

Question 6

goal of Fluid replacement therapy

Answer 6

maintain adequate intravascular volume to ensure cellular oxygen deliver and cardiac output

Question 7

Absolute hypovolemia

Answer 7

Results when fluid is lost thorough haemorrhage, gastrointestinal loss, drainage or diuresis.

Question 8

Relative hypovolemia

Answer 8

Fluid volume moves out of the vascular space into the extravascular space
- This is called third spacing.

Question 9

Hypovolemia signs

Answer 9

• Postural hypotension - pt feels faint when sitting up if BP falls >20mmHg
• Severe hypotension can cause nausea
• Vasoconstriction - cap refill > 2 seconds, hands begin to cool.
• Tachycardia, weak thready pulse
• Decrease UO, <0.5ml/kg/hr
• Sweating
• Poor skin turgor
• Agitation and anxiety.

Question 10

Hypervolemia

Answer 10

Too much fluid in the blood/body.

Question 11

Hypervolemia causes

Answer 11

Body’s normal stress response to surgery.
- ADH release leads to increased blood volume (hormone responsible for BP homeostasis)
- ACTH stimulates the adrenal cortex to secrete aldosterone, leading to significant sodium and fluid retention.
- Fluid shifts to the intravascular space from administration of hypertonic solutions

Question 12

Hypervolemia signs

Answer 12

• Ascites
• Oedema - hands, feet, ankles
• Strong and rapid pulse
• Change in respiratory pattern
• Crackles on auscultation
• Dyspnoea and orthopnoea
• High BP
• Jugular vein distension
• Increased CVP