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Difficulty: MediumPhysiological Adaptation

A nurse is assessing a client who sustained blunt abdominal trauma in a motor vehicle collision 2 hours ago. Which of the following assessment findings should the nurse identify as early compensatory signs of hypovolemic shock? Select all that apply.

  1. Apical pulse rate of 114 beats per minuteAnswer
  2. Blood pressure of 112/86 mm HgAnswer
  3. Cool, clammy skinAnswer
  4. D
    Urine output of 45 mL over the past hour
  5. E
    Bounding radial pulses

Answer

The early compensatory signs of hypovolemic shock are an apical pulse rate of 114 beats per minute, a blood pressure of 112/86 mm Hg, and cool, clammy skin.
In the early compensatory stage of hypovolemic shock, the body's sympathetic nervous system activates to maintain cardiac output and perfusion to vital organs. This neurohormonal response directly causes an increased heart rate, peripheral vasoconstriction (which narrows the pulse pressure by raising the diastolic reading), and the shunting of blood away from the periphery, leaving the skin cool and clammy.

Step-by-Step Solution

1
Identify the stage of shock described in the scenario.
The scenario asks for early compensatory signs of hypovolemic shock following blunt trauma.
Different stages of shock present with distinct clinical manifestations, and early recognition is critical.
2
Evaluate the vital signs for sympathetic nervous system compensation.
Tachycardia (114 bpm) and a narrowing pulse pressure (112/86 mm Hg) are identified as key compensatory mechanisms.
The body attempts to maintain cardiac output and tissue perfusion by increasing heart rate and vasoconstricting peripheral vessels.
3
Analyze the physical assessment findings for peripheral perfusion.
Cool, clammy skin is recognized as an early sign of blood shunting to vital organs, while bounding pulses are ruled out.
Vasoconstriction decreases blood flow to the skin and reduces the strength of peripheral pulses.
4
Review urine output expectations.
The urine output of 45 mL/hr is deemed normal and not indicative of the early compensatory phase.
Kidneys may maintain adequate output initially; a decrease to less than 30 mL/hr is typically a later, progressive sign.

Key Concept

Early recognition of hypovolemic shock relies on identifying subtle compensatory mechanisms, such as tachycardia, narrowing pulse pressure, and cool skin, before profound hypotension or oliguria occurs.
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Topics

Physiological Adaptation

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