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Brittney Hammant posted 27 July, 2022 17:16

Situation:

Mr X was a 75-year-old male who had presented to the emergency department with a reduced exercise tolerance over the past fortnight, becoming short of breath easily, and oedematous bilateral lower limbs. Mr X’s other medical history included heart failure, hypertension, hypercholesterolemia, obesity and a myocardial infarction in 2021 with stents. He stated he had not been adhering to his 1.5 litre fluid restriction as he had been on a holiday with his wife. Mr X was admitted to the ward with a clinical diagnosis of fluid overload on the background of decompensated heart failure for medication titration and observation. On arrival to the ward admission assessments found he was up five kilograms from his last admission, but his observations were unremarkable and he was resting comfortably. 

Whilst completing a routine assessment a few hours later Mr X stated he was “unable to lie flat” and felt like it was “difficult to breath”. 

Action: 

I conducted a respiratory assessment noting that he had increased work of breathing and was using accessory muscles, he was also sitting in the tripod position. On auscultation to his lung’s, crackles could be heard bilaterally at the bases on inspiration and expiration, which is indicative of air bubbling through the alveoli and bronchioles (Cox, Blackwood and Turner, 2019). The patient’s oxygen saturation was 88% on room air, respiration rate was 28, heart rate of 110bpm and he was diaphoretic. I completed an ECG which showed tachycardia but no acute ST segment changes from the admission ECG. After processing the information and cues I had collected regarding Mr X’s history and presentation, I suspected that Mr X was experiencing acute pulmonary oedema. The clinical criteria for acute pulmonary oedema includes, dyspnoea, orthopnoea, increased respiratory, increased work of breathing and hypoxia (Aissaoui, Hamzaoui and Price, 2022). 

Nasal flow oxygen was applied, and the treating team was contacted, who ordered a chest X-Ray, bedside echocardiogram, arterial blood gas, a stat dose of Furosemide 80mg intravenously and insertion of an indwelling catheter. The chest X-Ray was assessed and was indicative of pulmonary oedema. The arterial blood gas showed respiratory acidosis and hypoxia: pH 7.30, PaCo2 46mmHg and PaO2 56mmHg. CPAP was commenced as per the treating teams order and the patient was nursed 1:1 with the goal of ensuring effective oxygenation via CPAP and diuresis with a strict fluid balance chart. This aligns with the guidelines for the treatment of acute pulmonary oedema of using non-invasive ventilation such as CPAP to reduce hypercapnia and acidosis, and assist with work of breathing in patients with dyspnoea (Ko et al., 2020). 

Outcome: 

Once on CPAP the patients respiratory rate improved and their work of breathing decreased, Mr X began duiresing well via the indwelling catheter. Within a few hours Mr X was resting comfortably and a repeat ABG showed he was no longer hypoxic and his pH was within normal range, his electrolytes were closely monitored to ensure there was no imbalances due to his significant urine output and he was able to be stepped down to hiflow oxygenation therapy the following day. 

References: 

Aissaoui, N., Hamzaoui, O. and Price, S., 2022. Ten questions ICU specialists should address when managing cardiogenic acute pulmonary oedema. Intensive Care Medicine, 48(4), p.482. 

Cox, C., Blackwood, R. and Turner, R., 2019. Physical assessment for nurses and healthcare professionals. 3rd ed. John Wiley & Sons, Incorporated, p.116.

Ko, D., Beom, J., Lee, H., You, J., Chung, H. and Chung, S., 2020. Benefits of High-Flow Nasal Cannula Therapy for Acute Pulmonary Edema in Patients with Heart Failure in the Emergency Department: A Prospective Multi-Center Randomized Controlled Trial. Journal of Clinical Medicine, 9(6), pp.1-2.

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Urinary Retention

Grace Lawless posted 25 July, 2022 12:43

Situation: 

Mrs. X was a 24-year-old female with no significant past medical history. She was seven hours post a laparoscopic appendicectomy when she complained of abdominal pain. Upon completing a pain assessment, Mrs. X had 8/10 “burning” and “sharp” pain to her lower abdomen that was constant and worsened with sitting upright. She stated the pain started recently. Vital signs were attended and found to be unremarkable. Upon questioning the patient further, it was determined that she had not voided in the seven hours post her surgery. 

Action:

By this time, it was suspected that Mrs. X was experiencing urinary retention, however abdominal bleeding still needed to be ruled out as it is adverse side effect that can occur from surgery (Boucebci, et al., 2015). To rule out bleeding and confirm that the urinary bladder was full, inspection, percussion and palpation were used. The abdomen did not appear distended and was soft to palpate with a tympanic sound on percussion. This is indicative of a gas filled abdomen, ruling out bleeding (Boucebci, et al., 2015). A dull sound on percussion and a hard abdomen would indicate free fluid in the abdomen (Boucebci, et al., 2015). Next, I used these assessment tools on the patient’s bladder. To do this, I identified the landmark of the symphysis pubis. The symphysis pubis cradles the bladder and is located at the midline where the two pubic bones form a joint (Kowalik & Plante, 2016). A full bladder will rise above the symphysis pubis towards the umbilicus (Kowalik & Plante, 2016). Distention was noted upon inspection and the bladder was hard on palpation. Additionally, the area was tender with a dull sound on percussion, all signs of a full bladder (Kowalik & Plante, 2016). All cues identified ruled out abdominal bleeding and indicated urinary retention (Boucebci, et al., 2015) (Kowalik & Plante, 2016). 

Next, a bladder scan was attended by identifying the symphysis pubis to find the bladder. Bladder scanning has, on many occasions, been successful in confirming or excluding post operative urinary retention (Aurélien, et al., 2015). The bladder scan showed that Mrs. X had 750mls of urine in her bladder. I took the patient to the toilet to see if she could urinate, only voiding 50mls despite also using the double-voiding technique. After consulting the surgical team, an indwelling catheter was inserted which drained 700mls and provided the patient with much relief.  

Outcome: 

The outcome of this was that the patient’s pain was relieved, and complications of long-term urinary retention avoided. Urinary retention is a common complication that arises after a patient has anaesthesia or surgery (Kowalik & Plante, 2016). The analgesic drugs often disrupt the neural circuitry that controls the nerves and muscles in the urination process (Kowalik & Plante, 2016). Complications of urinary retention include Urinary tract infections as bacteria is not being flushed out of the urethra like it normally would with regular voiding (Kowalik & Plante, 2016). Bladder and kidney damage are also complications as your bladder may become stretched too far or for long periods (Kowalik & Plante, 2016). When this occurs, the muscles in your bladder may become damaged and no longer work correctly, this can cause urinary incontinence (Kowalik & Plante, 2016). Kidney damage can occur as the kidneys can become so full of urine that they swell and press on nearby organs (Kowalik & Plante, 2016). This pressure can damage your kidneys and, in some cases, may lead to chronic kidney disease and kidney failure (Kowalik & Plante, 2016). 

References

Aurélien, D. et al., 2015. Diagnosis of Postoperative Urinary Retention Using a Simplified Ultrasound Bladder Measurement. Anesthesia & Analgesia, 20(5), pp. 1033-1038.

Boucebci, S. et al., 2015. Postoperative abdominal bleeding. Diagnostic and Interventional Imaging, 96(7-8), pp. 823-831.

Kowalik, U. & Plante, M., 2016. Urinary Retention in Surgical Patients. Surgical Clinics , 96(3), pp. 453-467.