An individual is under observation on a trauma unit following a pelvic fracture sustained the previous day. The client is resting quietly in a supine position and reports that their discomfort is well-controlled. Upon obtaining the current vital signs, the practical nurse notes a blood pressure of 110/78 mm Hg, a pulse of 108 beats per minute, and respirations of 22 breaths per minute. A review of the admission flowsheet from twelve hours prior shows a blood pressure of 132/74 mm Hg, a pulse of 78 beats per minute, and respirations of 16 breaths per minute. The indwelling urinary catheter has drained 25 mL over the past hour. Which action must the nurse take first?
- Escalate the assessment findings to the supervising registered nurse without delay.Cevap
- BRecord the findings in the client chart since the current values represent a normal physiological stress response.
- CPerform a comprehensive pain assessment to determine if the elevated pulse requires analgesic administration.
- DDelegate the task of offering clear oral fluids to an assistive colleague to help increase the urinary output.
Cevap
The correct action is to immediately notify the registered nurse of the vital sign trends and decreased urine output, as these are subtle, early indicators of hypovolemic shock due to internal bleeding.
The client's narrowing pulse pressure, dropping systolic blood pressure, tachycardia, and decreased urine output are classic subtle signs of early compensatory shock. Pelvic fractures carry a significant risk of severe internal bleeding. Recognizing these trends and escalating care immediately reduces the risk of irreversible organ damage, which is the priority.
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Recognition of Early Compensatory Shock