A nurse is closely monitoring a client who sustained blunt abdominal trauma in a motor vehicle collision 2 hours ago. The client's baseline vital signs upon admission were: blood pressure 138/76 mm Hg, heart rate 80 beats per minute, and respiratory rate 16 breaths per minute. Which of the following current vital sign profiles provides the strongest evidence that the client is experiencing early compensatory hypovolemic shock?
- ABlood pressure 152/86 mm Hg, heart rate 102 beats per minute, respiratory rate 20 breaths per minute
- Blood pressure 126/94 mm Hg, heart rate 112 beats per minute, respiratory rate 24 breaths per minuteAnswer
- CBlood pressure 94/56 mm Hg, heart rate 136 beats per minute, respiratory rate 30 breaths per minute
- DBlood pressure 168/64 mm Hg, heart rate 56 beats per minute, respiratory rate 12 breaths per minute
Answer
The vital sign profile showing a blood pressure of 126/94 mm Hg, heart rate of 112 beats per minute, and respiratory rate of 24 breaths per minute is the correct answer.
The correct answer demonstrates a narrowed pulse pressure (32 mm Hg), tachycardia, and tachypnea. In early compensatory hypovolemic shock, the body's sympathetic nervous system initiates peripheral vasoconstriction to maintain cardiac output. This vasoconstriction raises the diastolic pressure while the systolic pressure remains relatively stable or decreases slightly, resulting in a narrowed pulse pressure. This is the earliest reliable cardiovascular indicator of shock.
Step-by-Step Solution
Key Concept
In early compensatory hypovolemic shock, sympathetic nervous system activation causes peripheral vasoconstriction, leading to an elevated diastolic blood pressure, a maintained systolic blood pressure, and a narrowed pulse pressure, alongside mild tachycardia and tachypnea.