A nurse is monitoring a client 4 hours after a complex open abdominal surgery. The client's baseline preoperative vital signs were blood pressure 126/78 mm Hg, heart rate 72 beats/min, and respiratory rate 14 breaths/min. Which combination of current assessment findings provides the most definitive early indication of compensatory hypovolemic shock?
- Blood pressure 124/86 mm Hg, heart rate 104 beats/min, accompanied by new-onset restlessness and cool extremitiesAnswer
- BBlood pressure 100/62 mm Hg, heart rate 74 beats/min, accompanied by drowsiness and unlabored respirations
- CBlood pressure 142/90 mm Hg, heart rate 112 beats/min, accompanied by severe incisional pain and flushing
- DBlood pressure 118/76 mm Hg, heart rate 86 beats/min, accompanied by 40 mL of dark amber urine output over the past hour
Answer
The correct answer is the finding of a narrowed pulse pressure (124/86 mm Hg), tachycardia (104 beats/min), restlessness, and cool extremities.
During the early (compensatory) stage of hypovolemic shock, the body's sympathetic nervous system activates to maintain perfusion to vital organs. This compensatory mechanism causes peripheral vasoconstriction, which results in cool extremities and an increased diastolic pressure (thereby narrowing the pulse pressure). Tachycardia occurs simultaneously to maintain cardiac output. Restlessness is often the very first neurological sign of slightly decreased cerebral oxygenation.
Step-by-Step Solution
Key Concept
Early Indicators of Hypovolemic Shock