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Difficulty: HardPhysiological Adaptation

An older adult client is receiving care for severe acute pancreatitis. The practical nurse (PN) is closely monitoring the client for the development of third-spacing and early hypovolemic shock. Which data collection findings should the PN identify as early indicators of this acute physiological complication? (Select all that apply.)

  1. Blood pressure of 108/88 mm Hg, compared to an admission baseline of 136/74 mm HgAnswer
  2. Apical heart rate of 118 beats/min with thready radial pulsesAnswer
  3. Urine output of 40 mL recorded over the previous 2 hoursAnswer
  4. New onset of restlessness and continuous picking at bed linensAnswer
  5. E
    Severe, continuous mid-epigastric pain that radiates to the back
  6. F
    Capillary refill time of 2 seconds in the upper extremities

Answer

The early indicators of hypovolemic shock include the narrowed pulse pressure, tachycardia with thready pulses, oliguria, and new onset of restlessness.
Early hypovolemic shock triggers sympathetic compensatory mechanisms. A narrowing pulse pressure, tachycardia with thready pulses, a sudden drop in urine output (< 30 mL/hr), and acute neurological changes (restlessness) all indicate decreased cardiac output and compromised tissue perfusion requiring immediate RN intervention.

Step-by-Step Solution

1
Analyze the clinical scenario and the specific complication being assessed.
The client has acute pancreatitis and is at risk for fluid shifting (third-spacing) leading to hypovolemic shock.
Identifying the target complication focuses the evaluation on signs of systemic circulatory compromise versus expected localized disease symptoms.
2
Evaluate each finding for evidence of compromised perfusion or compensatory shock mechanisms.
Narrowed pulse pressure, tachycardia, decreased urine output, and altered mental status are identified as shock indicators.
These findings reflect the body's attempt to maintain cardiac output (sympathetic response) and the resulting decrease in organ perfusion.
3
Differentiate acute systemic decompensation from normal findings and localized symptoms.
The severe pain is localized to the pancreas, and a 2-second capillary refill is a normal finding.
Separating expected localized symptoms from systemic ABC (Airway, Breathing, Circulation) changes is critical for accurate clinical prioritization.

Key Concept

Recognition of Early Hypovolemic Shock and Third-Spacing
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Topics

Physiological Adaptation

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