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Difficulty: MediumPhysiological Adaptation

A nurse receives the shift report on four clients admitted to a medical-surgical unit. Which client should the nurse assess first?

  1. A
    A client with chronic obstructive pulmonary disease (COPD) who has an arterial blood gas showing a pH of 7.36, a PaCO2PaCO_2 of 54 mm Hg, and an HCO3−HCO_3^- of 30 mEq/L.
  2. B
    A client admitted with bacterial pneumonia who has a temperature of 101.4∘F101.4^\circ F (38.6∘C38.6^\circ C) and reports coughing up rust-colored sputum.
  3. A client who had a cardiac catheterization via the right femoral artery four hours ago, and now exhibits a blood pressure of 112/90 mm Hg, a heart rate of 114 bpm, and new-onset agitation.Answer
  4. D
    A client with heart failure who has 1+ bilateral pitting edema in the lower extremities and a 2.2 lb (1 kg) weight gain over the past 24 hours.

Answer

The client who had a cardiac catheterization four hours ago and is exhibiting a narrow pulse pressure, tachycardia, and new-onset agitation.
The correct client requires immediate assessment because they are demonstrating classic early signs of hypovolemic shock. Following an arterial puncture like a cardiac catheterization, patients are at high risk for hemorrhage, including retroperitoneal bleeding. While the systolic blood pressure (112 mm Hg) appears acceptable at first glance, the pulse pressure has narrowed significantly to 22 mm Hg (112 minus 90). The sympathetic nervous system causes vasoconstriction to maintain perfusion, leading to this narrow pulse pressure, alongside tachycardia (114 bpm) and early hypoxia to the brain causing agitation. Immediate intervention is required to prevent cardiovascular collapse.

Step-by-Step Solution

1
Analyze the clinical data for each client to distinguish between expected, chronic disease manifestations and acute, life-threatening changes.
The clients with COPD, pneumonia, and heart failure are all displaying symptoms that are expected or stable for their underlying pathophysiological processes.
Differentiating baseline pathology from acute deterioration is the foundational step in clinical prioritization.
2
Evaluate the specific vital signs and neurological status of the post-cardiac catheterization client.
The blood pressure of 112/90 mm Hg reveals a narrow pulse pressure of 22 mm Hg (normal is 30-50 mm Hg). Combined with a heart rate of 114 bpm and new agitation, this indicates a sympathetic nervous system response.
Early recognition of shock requires identifying subtle compensatory mechanisms, such as peripheral vasoconstriction (narrowing pulse pressure) and tachycardia, before a late drop in systolic blood pressure occurs.
3
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
The post-procedural client is experiencing an acute circulatory deficit, likely due to internal bleeding or hematoma formation at the femoral access site.
Acute circulatory compromise poses an immediate threat to life and must be addressed before stable respiratory or fluid balance issues.

Key Concept

Recognition of early shock and clinical prioritization
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Topics

Physiological Adaptation

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