NU263 Unit 2 Hidden Hemorrhage Shock Analysis Example

A Heart Rate Held at 88 by Metoprolol: A Shock Case Analysis Tracing Hidden Bleeding Into the Thigh of a Composite 79-Year-Old Woman on the First Evening After Hip Fracture Repair, From a Narrowing Pulse Pressure to the Rapid Response Call

[Student Name]

Purdue University Global

NU263: Medical-Surgical Nursing III

Unit 2 Shock Case Analysis

[Instructor Name]

[Date]

The patient is composite; values and times are bracketed where illustrative, and transfusion, imaging and surgical decisions belong to the medical and orthopedic teams.

The Patient

[Mrs. E.], composite, 79, fell at home and fractured her right femur below the hip. She had an intramedullary nail placed at [1300]. She takes metoprolol for hypertension and atrial fibrillation, and apixaban, held two days before surgery. Preoperative hemoglobin [11.8] g/dL. Back on the unit at [1600]: blood pressure [138/76], heart rate [78], respirations [16], saturation [95] percent on [2] L, alert, pain [4].

The Timeline

[1800]: blood pressure [124/88], heart rate [84]. The systolic has fallen and the diastolic risen, so the pulse pressure, the difference between them, has narrowed from [62] to [36]. Her heart rate has barely moved. [1900]: blood pressure [118/90], heart rate [86], respirations [22]. She asks to go home and tries to climb out of bed. Urine [20] mL in the last hour. [2000]: the right thigh looks fuller. The student and nurse measure its circumference at a pen line [15] cm above the knee: [52] cm, compared with [47] cm on the left. [2030]: hemoglobin from an afternoon draw returns at [10.6]. [2100]: blood pressure [102/84], heart rate [88], respirations [26], cool feet. Rapid response called.

Why the Usual Sign Was Missing

In blood loss, the sympathetic nervous system raises the heart rate and narrows blood vessels to hold blood pressure (Cannon, 2018). A beta-blocker such as metoprolol blocks much of that heart rate response. Her pulse stayed in the [80]s while her body was losing volume. An older adult's heart rate response is often blunted even without medication. Relying on tachycardia as the alarm would have delayed recognition for hours.

Her pulse said she was fine because a pill told it to; the narrowing gap between her systolic and diastolic pressures told the truth earlier.

Pulse Pressure as the Early Voice

As blood volume falls, the heart pumps less with each beat, so the systolic pressure drops, while narrowing of the vessels raises the diastolic pressure. The result is a narrowing pulse pressure, often one of the first measurable changes in early hemorrhage. Hers narrowed from [62] to [36] over two hours while the mean pressure still looked acceptable.

Restless and Wanting to Leave

At [1900] she wanted to go home. Restlessness and confusion can be early signs of reduced blood flow to the brain, and in an older adult after surgery they are easily mistaken for delirium alone. Her rising breathing rate and falling urine output at the same time pointed toward perfusion.

A Thigh Measured at a Line

Hip fractures and the surgery to fix them can lose a substantial amount of blood into the thigh, much of it hidden in the tissues. Patients with hip fracture show large drops in hemoglobin related to the injury itself, not only the operation (Smith et al., 2011). Marking the thigh and measuring it turns an impression of swelling into a number that can be repeated.

A Hemoglobin That Lags

Her hemoglobin of [10.6] did not look alarming. Early in bleeding, the hemoglobin concentration can stay near normal because whole blood is lost; it falls later as fluid shifts in from the tissues and as IV fluids dilute what remains. A near-normal hemoglobin does not rule out significant bleeding.

Escalation With Its Targets

The rapid response call at [2100] used SBAR and named targets: a mean arterial pressure above [65], an hourly urine volume of at least half a milliliter for each kilogram she weighs, and a repeat hemoglobin. The team gave fluid, typed and crossmatched blood, transfused two units and arranged imaging of the thigh. The surgeon was notified. Her apixaban remained on hold (Harding et al., 2023).

Why Older Adults Hide Shock

Age itself changes the picture. Older hearts respond less to adrenaline, arteries are stiffer, and baseline blood pressures are often higher, so a reading that looks normal may already be low for her. Her usual systolic before surgery was in the [130]s to [140]s; a value of [118] was a meaningful fall for her even though it would be unremarkable in a younger adult. Comparing each number with the patient's own baseline, rather than with a textbook range, is one of the most useful habits on an orthopedic unit, where many patients are old and many take medicines that blunt the usual signs.

What the Assistant Could Have Reported

The nursing assistant took her [1900] vital signs and noticed she was trying to get out of bed. Had the reporting values included a rule for restlessness or a narrowing pulse pressure, that observation might have reached the nurse sooner. Directions to the assistant for postoperative orthopedic patients could include any new confusion or agitation, not only abnormal numbers.

Looking Back: When Could the Call Have Come?

With the narrowing pulse pressure at [1800] and restlessness at [1900], a call at [1900] would have been reasonable. The beta-blocker made the case harder, but the other signs were present. On patients taking beta-blockers, the nurse should look harder at pulse pressure, breathing rate, mental status, urine output and the surgical site.

References

Cannon, J. W. (2018). Hemorrhagic shock. New England Journal of Medicine, 378(4), 370-379. https://doi.org/10.1056/NEJMra1705649

Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C. (2023). Lewis's medical-surgical nursing: Assessment and management of clinical problems (12th ed.). Elsevier.

Smith, G. H., Tsang, J., Molyneux, S. G., & White, T. O. (2011). The hidden blood loss after hip fracture. Injury, 42(2), 133-135. https://doi.org/10.1016/j.injury.2010.02.015