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Difficulty: MediumPhysiological Adaptation

A nurse is evaluating a client 12 hours after a partial hepatectomy. The client is restless, anxious, and reports intense thirst. Assessment reveals pale, cool skin. Vital signs are: heart rate 122 bpm, blood pressure 104/86 mm Hg, and respiratory rate 26 breaths/min. The client's urinary output has been 40 mL over the past two hours. An arterial blood gas (ABG) analysis shows a pH of 7.32, PaCO2\text{PaCO}_2 of 33 mm Hg, and HCO3−\text{HCO}_3^- of 18 mEq/L. Based on these physiological findings, which of the following complications is the client most likely experiencing?

  1. Early hypovolemic shockAnswer
  2. B
    Primary respiratory acidosis
  3. C
    Uncontrolled postoperative pain
  4. D
    Intrinsic acute kidney injury

Answer

The client is most likely experiencing early hypovolemic shock.
The client is exhibiting classic signs of early hypovolemic (hemorrhagic) shock, a significant risk following a highly vascular procedure like a partial hepatectomy. The narrowing pulse pressure (the difference between systolic and diastolic pressure), tachycardia, oliguria, and pale, cool skin demonstrate the body's compensatory sympathetic response to maintain cardiac output. Furthermore, the ABG reveals metabolic acidosis with partial respiratory compensation, which occurs due to lactic acid accumulation from inadequate tissue perfusion.

Step-by-Step Solution

1
Analyze the vital signs and physical assessment findings.
The client has tachycardia, tachypnea, a narrowed pulse pressure (104 - 86 = 18 mm Hg), pale/cool skin, and intense thirst.
These are classic compensatory signs of sympathetic nervous system activation in response to decreased cardiac output and intravascular volume.
2
Evaluate the urinary output.
The output is 40 mL over two hours (20 mL/hr), which indicates oliguria.
Oliguria is a compensatory mechanism (activation of the RAAS pathway) to retain fluid and maintain blood pressure during volume depletion.
3
Interpret the arterial blood gas (ABG) results.
The pH is 7.32 (acidemia), HCO3−\text{HCO}_3^- is 18 mEq/L (metabolic acidosis), and PaCO2\text{PaCO}_2 is 33 mm Hg (partial respiratory compensation).
Inadequate tissue perfusion (shock) leads to anaerobic metabolism, producing lactic acid and causing metabolic acidosis. The tachypnea is attempting to blow off CO2 to compensate.
4
Synthesize the findings to identify the underlying complication.
All assessment data point to a systemic perfusion deficit.
Following highly vascular surgery like a hepatectomy, these combined physiological adaptations strongly indicate early hemorrhagic/hypovolemic shock.

Key Concept

Recognition of compensatory physiological mechanisms in early hypovolemic shock.
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Topics

Physiological Adaptation

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