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Difficulty: MediumPhysiological Adaptation

A nurse is evaluating a client who is receiving continuous intravenous fluid therapy for severe acute pancreatitis. Which assessment findings indicate the client is developing early hypovolemic shock? Select all that apply.

  1. Urine output of 25 mL over the past hourAnswer
  2. Heart rate increases from 86 to 118 beats per minuteAnswer
  3. Client becomes increasingly restless and agitatedAnswer
  4. D
    Systolic blood pressure decreases to 76 mm Hg
  5. E
    Extremities are warm and flushed to the touch
  6. F
    Arterial blood gas shows a PaCO2 of 48 mm Hg

Answer

The assessment findings indicating early hypovolemic shock are the decreased urine output, the increased heart rate, and the new onset of restlessness and agitation.
In early (compensatory) hypovolemic shock, the sympathetic nervous system stimulates an increase in heart rate to maintain cardiac output. Blood is shunted away from non-vital organs, leading to decreased renal perfusion and oliguria (typically less than 30 mL/hr). Additionally, early decreases in cerebral perfusion initially manifest as subtle neurological changes, such as restlessness, agitation, or anxiety. Blood pressure is typically maintained during this phase.

Step-by-Step Solution

1
Analyze the pathophysiology of severe acute pancreatitis.
Recognize that massive fluid shifts into the peritoneal cavity and systemic inflammation can cause profound intravascular volume depletion.
To identify the client's specific risk for developing hypovolemic shock.
2
Identify compensatory mechanisms associated with early shock.
The sympathetic nervous system activates, causing tachycardia, peripheral vasoconstriction, and decreased renal perfusion to maintain core blood pressure.
To distinguish early physiological responses from late decompensatory failure.
3
Evaluate the given assessment findings against early shock indicators.
Tachycardia, oliguria (less than 30 mL/hr), and altered mentation are classical early signs. Hypotension and acidosis are late signs, while warm skin indicates a different shock etiology.
To select the options that correctly match the early compensatory phase of hypovolemia.

Key Concept

Early Indicators of Hypovolemic Shock
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Topics

Physiological Adaptation

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