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Difficulty: HardPhysiological Adaptation

A nurse is caring for a client admitted 12 hours ago with severe acute pancreatitis. The client's current assessment reveals pale, diaphoretic skin and a total urine output of 25 mL over the past two hours. Current vital signs are: blood pressure 84/50 mm Hg, heart rate 136 beats/min, and respiratory rate 28 breaths/min. Arterial blood gas (ABG) results show a pH of 7.28, PaCO2 of 31 mm Hg, and HCO3- of 15 mEq/L. What is the priority nursing action?

  1. Infuse a prescribed rapid bolus of 0.9% sodium chloride.Answer
  2. B
    Administer prescribed intravenous sodium bicarbonate.
  3. C
    Initiate a prescribed continuous infusion of norepinephrine.
  4. D
    Insert a nasogastric tube and connect to low intermittent suction.

Answer

The correct action is to rapidly infuse isotonic fluids to treat the underlying hypovolemic shock caused by third-spacing.
The client is experiencing severe hypovolemic shock as a result of massive retroperitoneal fluid shifts (third-spacing) characteristic of severe acute pancreatitis. The hypotension, tachycardia, oliguria, and resulting lactic acidosis (demonstrated by the ABG values) require immediate intravascular volume expansion. Isotonic crystalloid infusion is the primary life-saving action to restore perfusion.

Step-by-Step Solution

1
Analyze the vital signs and clinical assessment data.
The client exhibits severe hypotension, tachycardia, oliguria, and diaphoresis, which are classic signs of hypovolemic shock due to severe third-spacing common in acute pancreatitis.
Identifying the primary physiological derangement dictates the urgency and type of intervention required.
2
Interpret the arterial blood gas (ABG) results in the context of the clinical picture.
The ABG shows a metabolic acidosis (low pH, low HCO3-) with partial respiratory compensation (low PaCO2). This is lactic acidosis resulting from inadequate cellular perfusion.
Understanding the etiology of the acid-base imbalance prevents inappropriate interventions that only treat the lab values.
3
Determine the highest priority intervention using the ABCs and principles of shock management.
Restoring intravascular circulating volume (Circulation) with isotonic fluids is the definitive first-line treatment to reverse the hypoperfusion and correct the secondary acidosis.
Without adequate fluid volume, other interventions (like vasopressors) are ineffective and potentially harmful.

Key Concept

Management of hypovolemic shock and third-spacing in acute pancreatitis
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Topics

Physiological Adaptation

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