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Difficulty: MediumPhysiological Adaptation

An 82-year-old client is receiving care on the medical-surgical unit 12 hours after an open bowel resection. Which assessment findings should the practical nurse (PN) recognize as early indicators of potential hypovolemic shock that must be reported to the registered nurse (RN) immediately? (Select all that apply.)

  1. Heart rate of 114 beats per minute with weak peripheral pulsesAnswer
  2. Sudden onset of agitation and attempting to pull at the surgical dressingAnswer
  3. Blood pressure of 102/68 mm Hg, down from a preoperative baseline of 138/82 mm HgAnswer
  4. Urine output of 35 mL collected in the drainage bag over the past two hoursAnswer
  5. E
    Throbbing incisional pain rated as 7 on a 0 to 10 scale during repositioning
  6. F
    Oral temperature of 99.2°F (37.3°C) and warm extremities

Answer

The correct indicators of hypovolemic shock are a rapid heart rate with weak pulses, sudden agitation, a significant drop in baseline blood pressure, and abnormally low urine output.
Hypovolemic shock occurs when there is a significant loss of blood or fluids, which is a major risk following abdominal surgery. Early signs manifest as the body attempts to compensate for decreased perfusion. A rapid heart rate (tachycardia) and weak pulses occur because the heart must pump faster to circulate the reduced volume. A significant drop in blood pressure from the client's baseline indicates that these compensatory mechanisms are failing. Decreased urine output (averaging 17.5 mL/hr in this scenario, which is below the 30 mL/hr minimum) occurs because blood is shunted away from the kidneys to protect vital organs. Sudden agitation or restlessness is frequently the earliest sign of shock due to a reduction in oxygen delivery to the brain.

Step-by-Step Solution

1
Analyze the clinical scenario and the client's risk profile.
The client is an older adult, 12 hours post-abdominal surgery, placing them at high risk for hemorrhage and fluid shifts leading to hypovolemia.
Identifying the primary complication risk provides context for evaluating which symptoms are life-threatening.
2
Evaluate the cardiovascular and renal data for signs of decreased perfusion.
Tachycardia (114 bpm), relative hypotension (drop from 138/82 to 102/68), and oliguria (35 mL over 2 hours) all strongly indicate a loss of circulatory volume.
The body compensates for low blood volume by increasing heart rate and shunting blood away from the kidneys, reducing urine output.
3
Assess neurological findings in the context of physiological adaptation.
The new onset of agitation is a classic early sign of cerebral hypoxia.
The brain is highly sensitive to reduced oxygen delivery, making acute behavioral changes a priority assessment.
4
Differentiate critical indicators from expected postoperative findings.
Incisional pain with movement and a mild temperature elevation (99.2°F) are identified as expected normal responses to tissue trauma.
Safe nursing care requires prioritizing ABCs (Airway, Breathing, Circulation) over expected secondary discomforts.

Key Concept

Early Recognition of Hypovolemic Shock in Postoperative Clients
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Topics

Physiological Adaptation

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