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Adult Nursing Skills On Complex Care
Adult Nursing Skills On Complex Care
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Adult Nursing Skills Underpinning Complex Care 2
Introduction
This essay examines the complications associated with the named patient after the
resection of the bladder tumour. The article discusses the pathophysiology of bladder cancer and
linking it to different types of shock. The essay will describe different types of shock to show
their relations to patient’s surgery, and perform a diagnosis for hypovolemic shock based on the
symptoms and the three stages of hypovolemic shock. The essay will explain how the patient can
be treated via an individualised approach in the form of an ABCDE assessment under nursing
management care. Adult nursing requires competence to meet the physical and mental health of
adult patients, including those that need end-of-life care (NMC 2010). The ABCDE treatment
strategy will emphasise on patient’s airways, breathing, circulation, disability, and exposure as
well as how they deliver on patient-centred care. The short-term and long-term holistic
management care will be explored in the paper. Besides, the essay will focus on pharmacology
and the different types of medication that can be used for managing hypovolemic shock and
shock and frank haematuria using medication. Such consideration will entail medication doses,
side effects, and contraindications. More so, the essay will outline a plan of on-going care to
meet the individual needs of the patient. The consent of the patient will be informed in all
treatment areas alongside evidence-based practice and compliance with the NMC (2018)
standards.
Main Body
Bladder Cancer
Bladder cancer is one of the most prevalent neoplasms of the urinary system (Kim, 2018).
The urinary bladder consists of four layers, that is, the serosa, muscularis, mucosa, and
Adult Nursing Skills Underpinning Complex Care 3
submucosa (Kim, 2018). The mucosa comprises of five to a seven-thick layer of cells of the
stratified non-squamous epithelium. The bladder cancer initiates from the urothelium. About
90% of the histological types of bladder cancer are urothelial carcinoma. Urothelial carcinoma
involves the invasion of the underlying membrane or lamina propria by the neoplastic cells of the
urothelial origin. (Woo and Cho, 2018) The World Health Organisation (WHO) (2016)
histopathology, which impacts on risk stratification and patient management. The infiltrating
urothelial carcinoma has a variable history (Casey, Catto, Cheng, Cookson, Herr, Shariat, Witjes,
and Black, 2015). The development of urothelial carcinoma occurs in two distinct pathways that
are related to papillary and flat lesions based on their morphology and pathway (Humphrey,
Moch, Cubilla, Ulbright, and Reuters, 2016). Tumour progression and poor prognosis are
associated with copy number alterations and genetic instability of the patient.
However, pathology plays a significant role in the management of bladder cancer. For
example, most patients with non-muscular invasive bladder cancer that correlated show
improved overall survival and prognosis at initial diagnosis (Babjuk, Burger, Capuon, Cohen,
Comperat, Hernadez, Kaasinen, Palou, Roupret, et al., 2017). Besides, the identification of the
level of invasion is critical to the pathologic assessment of the urothelial carcinoma for proper
staging of the condition. Bladder cancer can be multifocal or unifocal, though the majority of
patient cases present the former (Humphrey et al., 2016). The pathology report of the patient
should entail tumour local, grade and depth, presence or absence of carcinoma in situ, and
presence of the detrusor muscle in the examined specimen (Kim, 2018). For complex scenarios,
recommended. Since the patient is more than 60 years, the common symptoms of bladder cancer
Shock
Shock can be physiological or psychological, where the latter is traumatic events or acute
stress disorder, while the former has multiple causes. According to Medlineplus (2020), the
shock is considered a life-threatening that takes place when a person’s body does not receive
sufficient blood flow. As well, physiologic shock can be triggered by an injury or condition that
interferes with the regular flow of blood in the body. In such a situation, the body cells and
organs do not receive an adequate supply of oxygen and nutrients to perform their normal
functions.
Types of Shock
The major types of shock include obstructive shock, which occurs when blood is blocked
from reaching its destination. Obstructive shock is primarily caused by the interruption of blood
flow or pulmonary embolism (Medlineplus, 2020). Also, obstructive shock can be caused by
other conditions that can trigger air or fluid build-up in the chest cavity. For instance,
haemothorax, where blood or fluids occupies the space between chest wall and lung,
pneumothorax, a condition of a collapsed lung, and cardiac tamponade, where fluids or blood
occupies the space between the heart and its muscles can lead to obstructive shock (Tintanalli,
2010).
Similarly, cardiogenic shock occurs due to damage to a person’s heart, which can be
caused by damages in the heart muscle, irregular heartbeats, or slow heart rate (Ballas and
Roberts, 2018). As well, the distributive shock is enhanced by body conditions that lead to loss
of shape of the blood vessels. By losing their tone, blood vessels might not have adequate blood
Adult Nursing Skills Underpinning Complex Care 5
pressure to supply the organs. Brain injuries or drug toxicities can lead to distributive shock.
Symptoms for distributive shock include low blood pressure, loss of consciousness (Gayet,
Prieto, Shakur, Ageron, Roberts, et al., 2018). Also, the anaphylactic shock is a subtype of
distributive shock caused by severe or systemic induction of Type I hypersensitivity that often
leads to degranulation of mast cells and basophils. Septic shock is a subtype of distributive shock
triggered by microbial infections (Ballas and Roberts, 2018). Neurogenic shock is considered
under the distributive type of shock caused by the reduced peripheral sympathetic nervous
system (SNS) vasomotor tone. Also, hypovolemic shock occurs when the body gets an
insufficient supply of blood due to severe blood loss or other injuries. Haemorrhagic shock is a
type of hypovolemic shock occurring due to blood loss, with traumatic injury being the leading
cause. Haemorrhagic shock can also happen because of bleeding from gastrointestinal (GI),
As a result of extracellular fluid loss, hypovolemic shock can occur due to various
aetiologies. For example, gastrointestinal losses are realised when the GI tract cannot reabsorb
the fluids due to retractable vomiting, diarrhoea, or external drainage (Udwadia, 2014). As well,
renal losses of salt and fluid can trigger hypovolemic shock. Significant fluid loss from the skin
in a hot and dry climate can lead to hypovolemic shock. Also, third-spacing sequestration of
In the First Stage, which is the earliest phase of the hypovolemic shock, the patient is
likely to have lost 15% or 750 ml of their total blood volume (Weyker, Webb and Brentjens,
2017). At this point, it can be difficult to diagnose the patients since the blood pressure and
Adult Nursing Skills Underpinning Complex Care 6
breathing rates are still normal. However, the appearance of the skin, paleness, is the most
In the Second Stage, the patient is likely to have lost 30% or 1500 ml of blood volume; it
is marked by increased heart and breathing rates, which makes the diagnosis less challenging
(Weyker et al., 2017). The patients are likely to sweat more and increase anxiety and
restlessness. However, the blood pressure might be within the normal range. The diastolic
In Stage Three, the patient would have lost 30-40% or up to 2000 ml of blood volume
(Weyker et al., 2017). The systolic pressure is likely to be not more than 100 mm Hg. The heart
rate is likely to increase to above 120 beats per minute. The breathing rate will be rapid at
approximately 30 breaths per minute (Weyker et al., 2017). The patients might depict signs of
mental discomfort, including anxiety and agitation. The skill will be more pale and cold and
sweaty.
For Stage Four, the person is definitely at a critical condition because they have
experienced loss of more than 40% of total blood volume (Weyker et al., 2017). The pulse rate
will be weak but extremely rapid heart rate. At this point, the breathing is faster and difficult.
The systolic blood pressure will be below 70 mm Hg. As well, heavy sweating, extremely pale
Overall, based on the description, the named patient seems to be in stage three of the
hypovolemic shock.
Apart from dehydration, trauma is considered one of the frequent causes of hypovolemia
in patients (Udwadia, 2014). Precipitating factors in a patient include that can induce
Adult Nursing Skills Underpinning Complex Care 7
hypovolemic shock include GI fistula, gastric tube, ileus, vomiting, fever, diarrhoea, gastric tube,
hyperglycaemia, and renal dysfunction. The loss of fluid from dehydration is primarily
comprised of plasma as opposed to whole blood, like in trauma cases. Besides, the reduction in
the volume of circulating blood leads to low venous returns regardless of its cause, and arterial
hypotension is realised in sufficiently severe hypovolemia (Webb et al., 2014). The systemic
contractility, and tachycardia. In such regards, systemic blood pressure could remain stable for
the on-going hypovolemia. Myocardia failure can be increased myocardial demand for oxygen
alongside decreased tissue perfusion. The patient can also produce acidosis because of the
A patient can lose up to 10% of blood volume without affecting their arterial pressure and
cardiac out, but more than that reduces cardiac output and oxygen delivery to the tissues and
organs (Weyker et al., 2017). Arterial pressure declines with a loss of more than 20% of total
blood volume. Hypovolemia and hypotension have differential impacts on organ functioning.
For instance, alpha-adrenergic activity is relatively higher in the splanchnic organs, making the
patient prone to hypovolemic shock and hypotension (Weyker et al., 2017). As well, ischemia is
likely to develop from the reduced GI perfusion, especially in the mucosa of the gut leading to
compromised mucosal integrity. The impaired gut barrier functioning permits the translocation
of bacteria, and endotoxins are precipitating a systemic inflammatory response because of shock.
In severe cases of hypovolemia, the pathophysiologic processes might induce sepsis (Ballas and
Roberts, 2018). In such regards, the named patient is vulnerable to multi-organ failure as a
Based on the case description, hypovolemic shock is the first suspected in the 70-year-old
patient triggered by the frank haematuria. Hypovolemic shock involves rapid loss of fluids
leading to multiple organ failure due to insufficient circulating volume and subsequent perfusion.
As well, the low blood pressure below 100 mm HG, drowsiness, fatigue, and faster heartbeat rate
above 120 beats per minute, among other vital signs are manifested in hypovolemic shock. The
presentation of the four-second capillary refill time and the full urinal catheter after an hour
signifies that Daniel possibly had ruptured renal arteries meaning he was having a blood loss
(Nolan and Pullinger, 2014). The moderate haematuria had probably advanced and became
gross, though the level of bleeding cannot be quickly determined. Due to urgency and adverse
patient’s condition. Apart from being a life-threatening complication, hypovolemic shock can
At the end of life care, gross haematuria is a more distressing complication to patients
and their families. In such consideration, nurses have to provide optimal and supportive care to
patient’s situations by combining skills between nursing and medical teams, communicating the
patient’s goals, and relieving him from symptom burden. However, since the patient’s case has
progressed to hypovolemic shock that can alter the terminal trajectory, there is a need for
After a hypovolemic shock, functions of the endothelium are highly altered because of
ischemia of the endothelial cells and reperfusion of the resuscitation with fluids. Besides, the
cause of the hypovolemic shock is first determined since it informs on the treatment modality to
fluids to be performed to minimize tissue ischemia. Hypovolemic shock occurs from either blood
or extracellular fluid loss (Yunos, Bellomo, Glassford, Sutcliffe, Lam, et al., 2015). The type of
fluid and rate of replacement is considered when replacing fluid for the hypovolemic shock
patient.
Both history and physical examination of the patient is vital in testing for hypovolemic
shock. For instance, the mentioned patient has a history of recent surgery. The full urinary
catheter signifies fluid loss. Some non-specific physical evaluation can be useful in determining
the presence of hypovolemic shock, like pale skin, reduced jugular venous distension, and
dryness in the mucous membranes (Udwadia, 2014). The patient can also appear sweaty,
values. For instance, increased blood-urea-nitrogen (BUN) level and serum creatinine are
realised due to prerenal kidney failure (Binhas et al., 2011). Even though the effects of the acid-
base balance vary among individuals with significant GI losses, the patient is likely to
demonstrate lactic acidosis from increased anaerobic metabolism. For cases of haemorrhagic
shock, the patient will have severely decreased amounts of haemoglobin and haematocrit.
Hypovolemic patients are also likely to experience low-urinary sodium because of the kidneys
attempt to convert sodium into water to increase the volume of extracellular fluid. Blood volume
depletion can be suggested by fractional excretion of less than 1% sodium. Besides, increased
Similarly, the central venous pressure (CVP) can be used to assess the blood volume
status (Weyker et al., 2017). However, CVP’s sensitivity has been questioned due to possible
Adult Nursing Skills Underpinning Complex Care 10
compromise of the outcomes as a measure of volume following failure of the right-sided heart,
chest-wall compliance and ventilator settings. The measurement of variations in pulse pressure
responsiveness. As well, respiratory variations can be measured in inferior vena cava by taking
evaluations have only been validated among hypovolemic patients with irregular breaths or
arrhythmias. Though it has limits, volume responsiveness can be determined by echo on passive
For management, hypovolemic patients with haemorrhagic shock at early stages can be
subjected to the use of blood products over crystalloid resuscitation for better outcomes. As well,
balanced transfusion of plasma to platelets to packed red blood cells in the ration of 1:1:1 or
1:1:2 is useful in enhancing haemostasis (Annane, Siami, Jaber, Martin, Elastrous, et al., 2013).
Besides, for a patient with severe bleeding following surgery or trauma, anti-fibrinolytic
administration can be considered to minimise chances of death or major bleed. For a patient with
hypovolemic induced by fluid loses, rapid infusion of isotonic crystalloid solution is considered
at the earlier phase since the exact fluid deficit cannot be determined. Such consideration allows
for quick restoration of tissue perfusion. As well, fluid repletion can be examined through
measurements of blood pressure, urine output, mental status, and peripheral oedema. Various
techniques have been availed for measuring fluid responsiveness, like ultrasound, CVP
monitoring, and pulse rate variations (Annane et al., 2013). Unfortunately, vasopressors should
not be used for hypovolemic shock because they worsen tissue perfusion.
Moreover, crystalloid fluid resuscitation has been preferred for severe volume depletion
that is not related to bleeding. However, the chemistry of the patient, predetermined resuscitation
Adult Nursing Skills Underpinning Complex Care 11
volume, acid-base status, and physician preferences guides the types of crystalloid to be used
(Annane et al., 2013). Several isotonic fluids with low-chloride concentrations are commercially
available, like Ringer’s solutions and PlasmaLyte that considered balanced crystalloids (Gatey-
Sgeron et al., 2018). More importantly, the aetiology of extracellular fluid loss must be identified
Medication
When fluid administration, among other interventions, fails to reverse the hypovolemic
shock, pharmacological therapy is applied to treat the hypovolemic patient. The medications will
be prescribed based on the patient situation and cause of fluid loss. Vasoactive drugs, such as
norepinephrine, vasopressin, phenylephrine and arginine, are given to prevent the patient from
cardiac failure. Even though they can be prescribed in different situations, early use of the
vasopressors has been associated with poor health outcomes in hypovolemic shock and higher
mortality rates (Plurad, Talving, Lam, et al., 2011). No dosage of the vasopressors has been
However, dopamine is dose-dependent and can be used at low doses of five to 15 micrograms
per kilograms per minute in adrenergic activation to increase renal blood flow, heart rate, and
contractility (Cardenas et al., 2015). Vasopressors all administered intravenously, often through
continuous infusion to allowed for fast and desired outcomes. As well, since dehydration can be
secondary to hyperglycaemia, insulin is administered. For diarrhoeal cases, the patient will
receive antidiarrheal medication. In the case of vomiting, antiemetic drugs are provided.
On the other hand, adverse effects on the use of vasoactive drugs rest on the mechanism
of action. For instance, arrhythmias are one of the common adverse effects. Vasopressin can lead
chest pain, among others (Cardenas et al., 2015). As well, dopamine and epinephrine have been
associated with local tissue necrosis, pulmonary oedema, and tachycardia (Cardenas et al., 2015).
necrosis and reflex bradycardia. Norepinephrine has similar effects to epinephrine in addition to
(Cardenas et al., 2015). Adrenergic vasopressors are contraindicated for patients with
anaesthesia.
The primary prevention of hypovolemic shock is the focus of adult nursing care. The
preventive mechanisms are determined based on the possible causes guided by the vital signs,
like high pulse beats per minute, low blood pressure, or any post-surgery injury (Myburgh,
2018). The nursing assessment data encompasses ineffective tissue perfusion, deficit fluid
volume, risks of metabolic acidosis, and positive anxiety in the patient. Based on such
evaluation, the nursing care unit will have to maintain the patient’s fluid volume, pressure and
pulse at functional levels. The team must demonstrate an understanding of the causative factors
For evidence of intra-professionalism, an adult nurse needs to show their knowledge and
competence, consult with the working team, and effectively communicate (NMC, 2010). As
well, the nurses must demonstrate positive interpersonal attributes in practice and decision-
making to immediately improve the status of the hypovolemic patient. Through collaboration,
the nursing team will deliver high-quality care to the patient, address complex care issues,
Adult Nursing Skills Underpinning Complex Care 13
responsible for safe, person-centred, and evidence-based nursing. The adult nurses should be
compassionate, respectful, and dignified since the environment has significant impacts on their
mental health and wellbeing of hypovolemic patients. Partnership with other care professionals is
vital in understanding the underlying conditions of the patients and the situation at hand,
Conclusion
Overall, the mentioned patient suffers from the risk of hypovolemic shock due to
significant loss of the total blood volume. Based on the case presentation, the patient is in stage
three of hypovolemic shock. Due to the underlying conditions of bladder cancer and frank
haematuria, immediate medical and nursing intervention is appropriate for the patient to manage
the shock. History and physical examination assist in examining hypovolemic shock. Isotonic
crystalloid fluids can be used in the interventions. By observing the adverse effects and
contraindications, vasoactive drugs may be used as deemed appropriate. The complexity and
urgency of the case require collaboration and evidence-based nursing practice to deliver on high-
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