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Difficulty: MediumReduction of Risk Potential

A nurse is assessing a client who is 4 hours post-operative following an exploratory laparotomy. The nurse is monitoring for complications. Which of the following assessment findings should the nurse identify as early indicators of developing hypovolemic shock? Select all that apply.

  1. New-onset restlessness and mild agitation.Answer
  2. Blood pressure reading of 118/92 mm Hg, compared to a baseline of 130/80 mm Hg.Answer
  3. C
    Peripheral pulses palpated as +3 (bounding).
  4. D
    Skin that is warm and flushed to the touch.
  5. Urine output totaling 40 mL in the surgical catheter drainage bag over the past 2 hours.Answer
  6. F
    Incisional pain rated as 7 on a 0 to 10 scale during repositioning.

Answer

The early indicators of developing hypovolemic shock are new-onset restlessness and mild agitation, a narrowing pulse pressure (blood pressure changing from 130/80 to 118/92 mm Hg), and oliguria (urine output of 40 mL over 2 hours).
Early hypovolemic shock is characterized by compensatory mechanisms aimed at maintaining cardiac output and vital organ perfusion. The sympathetic nervous system activates, causing peripheral vasoconstriction (which narrows the pulse pressure) and shunting blood away from non-vital organs like the kidneys, resulting in oliguria. Mild cerebral hypoxia manifests as restlessness and agitation.

Step-by-Step Solution

1
Analyze the clinical scenario
The client is 4 hours post-exploratory laparotomy and is at high risk for hemorrhage and fluid volume deficit.
Identifying the primary risk factor helps anticipate potential complications.
2
Evaluate vital signs for compensatory mechanisms
The blood pressure shows a narrowed pulse pressure (from 50 mm Hg to 26 mm Hg), which is a classic early sign of compensatory vasoconstriction.
The sympathetic nervous system acts to maintain mean arterial pressure despite volume loss by increasing peripheral vascular resistance.
3
Assess organ perfusion indicators
Restlessness indicates mild cerebral hypoxia, and a urine output of 20 mL/hr indicates decreased renal perfusion.
The brain and kidneys are highly sensitive to decreases in cardiac output, making them excellent early indicators of shock.
4
Differentiate expected findings and other shock states
Bounding pulses and warm skin are incorrect for hypovolemia, and localized pain is an expected post-surgical finding.
Hypovolemia causes weak pulses and cool skin; localized pain does not indicate systemic hemodynamic instability.

Key Concept

Early Recognition of Hypovolemic Shock
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Topics

Reduction of Risk Potential

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