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Difficulty: MediumPhysiological Adaptation

A nurse is caring for a client admitted with acute pancreatitis. Which of the following assessment findings should the nurse identify as indicators that the client is developing systemic inflammatory response syndrome (SIRS)? Select all that apply.

  1. Heart rate of 112 beats/minAnswer
  2. Respiratory rate of 28 breaths/minAnswer
  3. White blood cell count of 16,500/mm³Answer
  4. D
    Core body temperature of 37.6°C (99.7°F)
  5. E
    Arterial PaCO2 of 42 mm Hg
  6. F
    Urine output of 45 mL/hr

Answer

The indicators of SIRS in this scenario include a heart rate of 112 beats/min, a respiratory rate of 28 breaths/min, and a white blood cell count of 16,500/mm³.
Systemic inflammatory response syndrome (SIRS) is a widespread inflammatory response to an insult, such as severe pancreatitis. It is defined by two or more of the following: temperature greater than 38.0°C or less than 36.0°C, heart rate greater than 90 beats/min, respiratory rate greater than 20 breaths/min (or PaCO2 < 32 mm Hg), and a white blood cell count greater than 12,000/mm³ or less than 4,000/mm³. The options presenting a heart rate of 112 beats/min, a respiratory rate of 28 breaths/min, and a WBC of 16,500/mm³ all exceed these thresholds and are clear indicators of SIRS.

Step-by-Step Solution

1
Recall the diagnostic criteria for systemic inflammatory response syndrome (SIRS).
SIRS is identified by the presence of two or more of the following: Temperature > 38.0°C or < 36.0°C, Heart rate > 90 beats/min, Respiratory rate > 20 breaths/min or PaCO2 < 32 mm Hg, and WBC > 12,000/mm³, < 4,000/mm³, or > 10% bands.
Accurate identification of SIRS is essential for recognizing early physiological decompensation.
2
Evaluate the client's vital signs and laboratory values against the SIRS criteria.
The heart rate of 112 beats/min, respiratory rate of 28 breaths/min, and WBC count of 16,500/mm³ all meet the criteria for SIRS.
Comparing client data to established clinical thresholds determines the presence of the syndrome.
3
Analyze the remaining options to confirm they do not meet SIRS criteria.
The temperature of 37.6°C is not > 38.0°C, the PaCO2 of 42 mm Hg is not < 32 mm Hg, and the urine output of 45 mL/hr is normal.
Eliminating distractors ensures that only true indicators of systemic inflammation are selected.

Key Concept

Systemic Inflammatory Response Syndrome (SIRS) Criteria
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Topics

Physiological Adaptation

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