Question

Jay James is a 24-year-old male who was rock climbing with his friends at a national park 25 miles from the nearest hospital when he suddenly lost his footing and slid 20 feet to the ground. Mr. James was alert and oriented when his friends reached him, and he could move all extremities quite easily. He had multiple scrapes over his anterior chest and a large gash over his left thigh (near the groin), which was bleeding profusely. His friends made a makeshift tourniquet, which slowed the bleeding. They immediately contacted the park ranger, who secured a helicopter to evacuate Mr. James to the nearest hospital. Two large-bore IVs were placed in each arm in-flight, and normal saline was administered. The flight medic placed a 100% non-rebreathing mask on Mr. James. Mr. James became disoriented and confused during the flight. Mr. James arrived in the emergency department (ED) in 45 minutes after the fall. On arrival in the ED, Mr. James is lethargic but responsive to painful stimuli. He has multiple abrasions over his chin and neck. His pulse oximetry is 99% on the non-rebreathing mask, so the ED team replaces the mask with a nasal cannula at 4 L/m. A repeat pulse oximeter reads 95% saturation. Vital signs are as follows: HR 130, BP 100/60, R 30 and TO 99.1°F. Skin is cool and clammy, nail beds are pale, and mucous membranes are dry. All pulses are palpable but weak and thready. Lungs are clear, heart sounds regular. Output via urinary catheter for the last hour is 20 mL.

Question 1

What is the most likely cause of Mr. James’s high heart rate and low blood pressure?

Question 2

If you were the nurse assigned to Mr. James, what would be your primary concerns at this time?

Question 3

What is the priority plan of care for Mr. James at this time?

Answer 1

Question 1

The most likely cause of Mr. James’s high heart rate and low blood pressure will be decreased blood volume in the body due to bleeding( Hypovolemia). When there is a decreased blood volume in the circulation, the body try to adjust it with pumping more blood to the circulatory system by contracting more in one minute(increased heart rate) and veins narrow to return more blood to heart as a compensatory mechanism. This cause increase in blood pressure.

Question 2

The primary concerns during Mr.James care is to stop the source of bleeding and obtain hemodynamic stability by restore blood volume through intravenous fluid management,there by prevent fatal complication like shock.

• Applying continuous pressure on the bleeding wound with sterile gauze and securing with elastic adhesive bandage will reduce the bleeding. However, immediate action to be taken and arrangement for operation theater should be done as soon as possible.
• Continuous cardiac monitoring is important.
• Blood or blood product transfusion can be considered and prepared in case of not attaining hemodynamic stability by intravenous fluid therapy.

Question 3

Since the bleeding has slow down with application of  tourniquet and fluid replacement therapy initiated prior to arrival to ED and initial assessment, airway maintanance and urinary output monitoring initiated in ED . These are the immediate care to be given for a patient with uncontrolled bleeding.Thus, the remaining plan of care for Mr. James include,

1. Close monitoring of vital signs, mental status and laboratory blood values are essential as patient has low blood pressure and confusion. Confusion can be a sign of decreased cerebral perfusion.

2. Keep the patient warm by providing blankets.

3. Prepare blood and blood products as soon as possible.

4. Administer intravenous medications like vasopressors, inotropic agents according to order.

5. Prepare the patient for suturing of the wound as soon as possible.