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Difficulty: HardPhysiological Adaptation

Shift report is completed for a client who underwent an exploratory laparotomy 24 hours ago for a severe bowel obstruction. Current assessment reveals a heart rate of 124 beats per minute, a respiratory rate of 28 breaths per minute, and a blood pressure of 96/68 mm Hg (a decrease from 118/74 mm Hg four hours ago). The client's extremities are cool to the touch, and urine output has been 45 mL over the past three hours. Arterial blood gas (ABG) analysis on room air indicates a pH of 7.28, PaCO2PaCO_2 of 30 mm Hg, HCO3−HCO_3^- of 15 mEq/L, and PaO2PaO_2 of 64 mm Hg. Based on these findings, which of the following nursing actions are appropriate? (Select all that apply.)

  1. Initiate a rapid intravenous infusion of an isotonic crystalloid solution.Answer
  2. Apply supplemental oxygen to maximize tissue perfusion.Answer
  3. C
    Administer intravenous sodium bicarbonate to reverse the respiratory acidosis.
  4. D
    Document the findings as a typical sympathetic nervous system response to postoperative pain.
  5. E
    Complete the scheduled sterile abdominal dressing change prior to notifying the healthcare provider.

Answer

The appropriate actions are to initiate a rapid intravenous infusion of an isotonic crystalloid solution and apply supplemental oxygen.
The correct actions prioritize the ABCs (Airway, Breathing, Circulation) in a client demonstrating signs of early shock. Tachycardia, a narrowing pulse pressure, oliguria, and metabolic acidosis indicate inadequate tissue perfusion. Administering supplemental oxygen maximizes the oxygen-carrying capacity, while rapid isotonic fluid administration restores intravascular volume.

Step-by-Step Solution

1
Evaluate the client's vital signs and urine output.
The client demonstrates tachycardia, tachypnea, a narrowing pulse pressure (28 mm Hg), oliguria (15 mL/hr), and cool extremities.
Recognizing early physiological deterioration is essential to prevent irreversible shock.
2
Interpret the arterial blood gas (ABG) results.
The values indicate a partially compensated metabolic acidosis with hypoxemia.
Accurately identifying the acid-base imbalance directs therapeutic interventions and rules out respiratory causes.
3
Prioritize nursing interventions based on the assessment findings.
The priority is to address circulation and breathing by administering intravenous fluids and supplemental oxygen.
Intervening for acute hemodynamic instability takes precedence over routine tasks or expected postoperative symptoms.

Key Concept

Early Recognition and Management of Shock
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Topics

Physiological Adaptation

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