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Difficulty: MediumPhysiological Adaptation

An emergency department triage nurse evaluates a client who sustained blunt force abdominal trauma in a motor vehicle collision. The nurse suspects the client is entering the compensatory stage of shock. Which of the following assessment findings support this physiological adaptation? Select all that apply.

  1. Resting heart rate of 118 beats per minuteAnswer
  2. Blood pressure reading of 114/96 mm HgAnswer
  3. Hypoactive bowel sounds in all four quadrantsAnswer
  4. D
    Warm, flushed skin on the upper and lower extremities
  5. E
    Mean arterial pressure of 48 mm Hg

Answer

The findings that support the compensatory stage of shock are a resting heart rate of 118 beats per minute, a blood pressure reading of 114/96 mm Hg (narrowing pulse pressure), and hypoactive bowel sounds.
During the compensatory stage of shock, the sympathetic nervous system triggers the release of epinephrine and norepinephrine. This physiological adaptation causes an increase in heart rate to maintain cardiac output and induces widespread peripheral vasoconstriction, which elevates diastolic blood pressure and results in a narrowed pulse pressure. Additionally, blood is strategically shunted away from non-vital organs, such as the gastrointestinal tract, leading to hypoactive bowel sounds.

Step-by-Step Solution

1
Analyze the client's risk factors and current clinical scenario.
The client suffered blunt abdominal trauma, placing them at high risk for internal hemorrhage and hypovolemic shock.
Identifying the etiology of shock determines the expected physiological response.
2
Recall the physiological mechanisms characteristic of the compensatory stage of shock.
The body activates the sympathetic nervous system and the renin-angiotensin-aldosterone system (RAAS) to maintain cardiac output and perfusion to vital organs.
Understanding compensatory mechanisms allows for the anticipation of specific clinical signs.
3
Evaluate each assessment finding against the expected physiological adaptations.
Tachycardia, a narrowing pulse pressure, and decreased gastrointestinal motility directly result from sympathetic stimulation and the shunting of blood away from non-vital organs.
Differentiating early compensatory signs from late progressive signs or alternative shock states ensures accurate clinical judgment.

Key Concept

Physiological Adaptation: Compensatory Mechanisms in Early Shock
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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