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Difficulty: Very hardPhysiological Adaptation

A nurse evaluates a client admitted with severe acute pancreatitis. The client is lethargic and exhibits carpopedal spasm when the blood pressure cuff is inflated. Current vital signs include a heart rate of 128 beats/min, blood pressure of 98/84 mm Hg, and respiratory rate of 28 breaths/min with an SpO2 of 96% on room air. The central venous pressure (CVP) is 1 mm Hg. Arterial blood gas results show a pH of 7.29, PaCO2 of 28 mm Hg, and HCO3- of 14 mEq/L. Which is the priority nursing action?

  1. Increase the rate of the continuous isotonic intravenous fluid infusion.Answer
  2. B
    Administer prescribed intravenous calcium gluconate.
  3. C
    Request a prescription for a continuous intravenous sodium bicarbonate infusion.
  4. D
    Prepare the client for emergent endotracheal intubation and mechanical ventilation.

Answer

The correct action is to increase the rate of the continuous isotonic intravenous fluid infusion.
The client is in severe hypovolemic shock due to third-spacing, which is common in acute pancreatitis. The narrow pulse pressure (14 mm Hg), tachycardia, and low central venous pressure (1 mm Hg) indicate an empty vascular space and profound circulatory collapse. The priority physiological intervention is aggressive fluid resuscitation to restore tissue perfusion. Improving perfusion will resolve the underlying cause of the metabolic (lactic) acidosis.

Step-by-Step Solution

1
Analyze the hemodynamic data.
The pulse pressure is extremely narrow (98 - 84 = 14 mm Hg), CVP is low (1 mm Hg), and the heart rate is high (128 beats/min).
These findings are classic indicators of profound hypovolemic shock caused by massive third-spacing of fluids, a hallmark of severe acute pancreatitis.
2
Evaluate the arterial blood gas (ABG) results.
A pH of 7.29 and HCO3- of 14 mEq/L indicate metabolic acidosis, while the PaCO2 of 28 mm Hg indicates partial respiratory compensation.
This confirms that the acid-base imbalance is driven by poor tissue perfusion (lactic acidosis), and the respiratory system is appropriately attempting to compensate.
3
Analyze the physical assessment findings.
Carpopedal spasm upon inflation of the blood pressure cuff is a positive Trousseau's sign.
This indicates hypocalcemia, which occurs in pancreatitis due to the binding of calcium to areas of fat necrosis.
4
Prioritize interventions using the Airway, Breathing, Circulation (ABC) framework.
Circulatory collapse is the most immediate threat to the client's life.
Aggressive fluid resuscitation is the primary physiological adaptation needed to restore perfusion, which will simultaneously treat the lactic acidosis.

Key Concept

Prioritization in Severe Acute Pancreatitis (Hypovolemic Shock vs. Electrolyte Imbalance)
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Topics

Physiological Adaptation

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