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Difficulty: MediumPhysiological Adaptation

A nurse is caring for a client admitted with severe acute pancreatitis who is receiving continuous intravenous normal saline at 100 mL/hr. The nurse reviews the client's vital signs and hourly urine output over the past four hours:

TimeBlood PressureHeart RateRespiratory RateUrine Output
08:00124/76 mmHg84 bpm16 breaths/min50 mL/hr
10:00118/80 mmHg96 bpm20 breaths/min35 mL/hr
12:00110/88 mmHg115 bpm24 breaths/min20 mL/hr

At 12:00, the client's arterial blood gas (ABG) results on room air are: pH 7.38, PaCO2\text{PaCO}_2 33 mmHg, HCO3−\text{HCO}_3^- 19 mEq/L, and PaO2\text{PaO}_2 86 mmHg. Based on these findings, which of the following is the priority nursing action?

  1. Notify the healthcare provider and anticipate a prescription for a rapid intravenous fluid bolus.Answer
  2. B
    Administer the prescribed as-needed intravenous opioid analgesic to manage suspected worsening abdominal pain.
  3. C
    Prepare to administer intravenous sodium bicarbonate to correct the client's uncompensated metabolic acidosis.
  4. D
    Assist the client into a high-Fowler's position and encourage the use of an incentive spirometer.

Answer

The correct action is to notify the healthcare provider and anticipate a prescription for a rapid intravenous fluid bolus.
The correct action addresses the client's deteriorating hemodynamic status. The trends in the vital signs demonstrate a narrowing pulse pressure (from 48 mmHg at 08:00 to 22 mmHg at 12:00), worsening tachycardia, tachypnea, and oliguria, which are classic early indicators of compensatory hypovolemic shock. Clients with severe acute pancreatitis are at high risk for profound fluid shifts (third-spacing). The arterial blood gas reveals a fully compensated metabolic acidosis, likely secondary to lactic acid buildup from poor tissue perfusion. The priority action is aggressive intravenous fluid resuscitation to restore intravascular volume and tissue perfusion.

Step-by-Step Solution

1
Analyze the trends in the client's vital signs and urine output.
The pulse pressure has narrowed significantly (from 48 mmHg to 22 mmHg), heart rate has increased to 115 bpm, respiratory rate has increased, and urine output has dropped to 20 mL/hr.
Recognizing trends is essential to detect early compensatory mechanisms in shock.
2
Interpret the arterial blood gas (ABG) values.
pH 7.38 (normal but on the acidic side), PaCO2\text{PaCO}_2 33 mmHg (low), HCO3−\text{HCO}_3^- 19 mEq/L (low). This indicates a fully compensated metabolic acidosis.
Identifying the acid-base balance helps confirm poor tissue perfusion and lactic acid accumulation secondary to hypovolemia.
3
Determine the priority nursing intervention based on the physiological findings.
The most critical issue is impending hypovolemic shock due to third-spacing of fluids, requiring immediate fluid resuscitation.
According to prioritization principles (ABCs and Maslow's hierarchy), restoring adequate circulation and tissue perfusion is the immediate life-saving priority.

Key Concept

Early recognition of hypovolemic shock and prioritization of circulatory resuscitation in clients with severe fluid shifts.
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Topics

Physiological Adaptation

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