NSB236 Questions and Correct Answers the Latest Update
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Module
NSB236
Institution
NSB236
Situation
Mr. Johnson Butterworth is a 72-year-old man who was initially admitted 3 days
ago for the conservative managed of a small bowel obstruction, which has now
required surgical intervention. Mr Butterworth is being admitted to your ward
post-operatively and has undergone a left hemico...
NSB236 Questions and Correct
Answers the Latest Update
Situation
Mr. Johnson Butterworth is a 72-year-old man who was initially admitted 3 days
ago for the conservative managed of a small bowel obstruction, which has now
required surgical intervention. Mr Butterworth is being admitted to your ward
post-operatively and has undergone a left hemicolectomy with approximately
15cm of necrotic small bowel resected and a double-barreled ileostomy brought
out, a peritoneal washout performed, times two Redivacs in situ to drain the
pericolic gutter (Right side 100mls, Left side 80mls of haemoserous fluid) and
mid-line abdominal closure performed. Intra-operatively, Mr. Butternut
received 4 units of blood and an additional 2 litres of Hartman's solution. A quad
(4) lumen central venous line, a Salem sump nasogastric tube (NGT) and an
indwelling urinary catheter (IDC) were inserted. On admission at 16:15 hours he
has Hartman's solution running at 125mls/hour, and an urinary output
✓ Key points:
✓ Decreased urinary out indicator of decreased organ perfusion as evidenced by
decreased blood pressure.
✓ Hypotension - related to the inflammatory process associated with sepsis and
vasodilatory effects of the inflammatory mediators.
✓ Tachycardia - compensatory response to decreased blood pressure and the bodies
attempt to improve cardiac output (stroke volume x heart rate) secondary to the
decreased blood pressure and organ perfusion.
✓ Tachypnea - an incresed respiratory effort to improve oxygenation secondary to
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compromise organ perfusion and decreased Oxygenation (supplemented via Hudson
mask)
Mr. Johnson Butterworth is a 72-year-old man who was initially admitted 3 days
ago for the conservative managed of a small bowel obstruction, which has now
required surgical intervention. Mr Butterworth is being admitted to your ward
post-operatively and has undergone a left hemicolectomy with approximately
15cm of necrotic small bowel resected and a double-barreled ileostomy brought
out, a peritoneal washout performed, times two Redivacs in situ to drain the
pericolic gutter (Right side 100mls, Left side 80mls of haemoserous fluid) and
mid-line abdominal closure performed. Intra-operatively, Mr. Butternut
received 4 units of blood and an additional 2 litres of Hartman's solution. A quad
(4) lumen central venous line, a Salem sump nasogastric tube (NGT) and an
indwelling urinary catheter (IDC) were inserted. On admission at 16:15 hours he
has Hartman's solution running at 125mls/hour, and an urinary output of 70-
90ml
✓ Elevated white cell count: indication of increased white cell activity in response to a
systemic infection, in order to fight the invading bacteria.
✓ Increased creatinine - indication of decreased renal function secondary to decreased
blood pressure and renal perfusion, that has occurred secondary to the vasodilatory
effects of sepsis and evidenced by decreased urinary output.
✓ Increased Alanine Aminotransferase (ALT) - liver enzyme: increased levels secondary
to decreased organ perfusion as a result of hypotension and decreased end-organ
perfusion, as a result of the vasodilatory effects of sepsis. In low blood pressure
states, blood is shunted to support critical organs such as the heart, respiratory
system and brain.
Based on the above assessment findings outline the compensatory processes
that have been initiated.
✓ Heart rate has increased as a compensatory process to improve cardiac output and
in turn blood pressures (CO = HRX SV)
✓ Increase respiratory rate to compensate for decreased oxygenation as a result of
decreasing blood pressure and oxygenation
✓ Decreased blood pressure and perfusion to the kidney results in decreased urinary
out which would trigger the renin-angiotensin aldosterone system resulting in fluid
retention as a means to try and improve circulating volume and blood pressure.
Which two underlying shock-related factors cause the majority of clinical
manifestations associated with shock?
✓ Activation of compensatory mechanisms
✓
✓ Inadequate oxygen delivery
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