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Difficulty: MediumPhysiological Adaptation

An emergency department triage nurse assesses a young adult who sustained blunt abdominal trauma after striking a bicycle handlebar. Over the past 45 minutes, the client's heart rate has trended from 86 to 116 beats per minute, and their blood pressure has shifted from 120/72 mm Hg to 108/86 mm Hg. Based on these physiological changes, what is the priority nursing action?

  1. Initiate rapid infusion of intravenous isotonic crystalloid fluids.Answer
  2. B
    Obtain a 12-lead electrocardiogram to evaluate for myocardial contusion.
  3. C
    Request a prescription for a negative chronotropic medication to lower the heart rate.
  4. D
    Elevate the head of the bed to a high-Fowler's position to promote oxygenation.

Answer

The priority action is to initiate a rapid infusion of intravenous isotonic crystalloid fluids.
The client is exhibiting classic signs of the compensatory stage of hypovolemic shock, likely due to internal hemorrhage from the abdominal trauma. As blood volume drops, the sympathetic nervous system triggers an increased heart rate to maintain cardiac output and peripheral vasoconstriction, which raises the diastolic blood pressure and narrows the pulse pressure. The most critical intervention is to aggressively restore intravascular volume with isotonic crystalloids.

Step-by-Step Solution

1
Analyze the vital sign trends.
The heart rate increased significantly (86 to 116 bpm) while the pulse pressure narrowed dramatically (from 48 mm Hg to 22 mm Hg).
Identifying changes in vital signs over time is critical for detecting physiological deterioration before profound hypotension occurs.
2
Correlate the findings with the mechanism of injury.
Blunt abdominal trauma combined with tachycardia and a narrowing pulse pressure indicates compensatory hypovolemic shock (internal bleeding).
The body compensates for lost circulating volume by increasing the heart rate and vasoconstricting, which raises the diastolic blood pressure and narrows the pulse pressure.
3
Determine the priority nursing intervention.
Fluid resuscitation with isotonic crystalloids is required immediately.
In hypovolemic shock, restoring intravascular volume is the primary intervention to maintain cardiac output and tissue perfusion.

Key Concept

Early Recognition and Management of Hypovolemic Shock
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Topics

Physiological Adaptation

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