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Difficulty: EasyPhysiological Adaptation

A client is 4 hours postoperative following a bowel resection. The surgical dressing is saturated with bright red blood, and the hemovac drain contains 300 mL of fresh sanguineous fluid. Which assessment findings indicate the client is developing early hypovolemic shock? Select all that apply.

  1. Heart rate of 118 beats per minuteAnswer
  2. New onset of restlessnessAnswer
  3. C
    Bounding peripheral pulses
  4. Capillary refill time of 5 secondsAnswer
  5. E
    Urine output of 60 mL per hour

Answer

The assessment findings indicating early hypovolemic shock are a heart rate of 118 beats per minute, new onset of restlessness, and a capillary refill time of 5 seconds.
In early hypovolemic shock, the body's compensatory mechanisms activate the sympathetic nervous system to preserve tissue perfusion. This physiological response manifests as an increased heart rate (tachycardia) to boost cardiac output, peripheral vasoconstriction (prolonged capillary refill) to redirect blood flow to essential organs, and early signs of cerebral hypoxia such as restlessness or anxiety.

Step-by-Step Solution

1
Identify the primary clinical risk presented in the scenario.
The client has acute blood loss, putting them at risk for hypovolemic shock.
Recognizing the risk guides the focus toward early signs of decreased perfusion.
2
Evaluate each option against the expected physiological changes in the compensatory stage of shock.
Tachycardia, delayed capillary refill, and altered mental status are early signs. Normal urine output and bounding pulses contradict the pathophysiology of hypovolemia.
Sympathetic nervous system activation causes specific, predictable vital sign and assessment changes to maintain blood pressure.

Key Concept

Early Indicators of Hypovolemic Shock
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Topics

Physiological Adaptation

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