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Zorluk: ZorPhysiological Adaptation

During the afternoon shift, the practical nurse collects data on an 82-year-old client admitted for acute pyelonephritis who is receiving intravenous antibiotics. Which specific clinical findings should the nurse recognize as early signs of physiological decompensation and impending septic shock? Select all that apply.

  1. Apical pulse of 116 beats/minute with a blood pressure of 94/72 mm HgCevap
  2. New onset of restlessness and disorientation to the current locationCevap
  3. Total urinary output of 25 mL over the past two hoursCevap
  4. D
    Reports of continuous, dull aching in the lower back and flank areas
  5. E
    Oral temperature of 99.2°F (37.3°C) with a respiratory rate of 16 breaths/minute
  6. F
    Cloudy, dark amber-colored urine noted in the indwelling catheter tubing

Cevap

The correct findings indicating early impending shock are an elevated heart rate with a narrowing pulse pressure, new onset of restlessness or confusion, and a significantly decreased urine output.
In early (compensatory) shock, the body activates the sympathetic nervous system to maintain vital organ perfusion. This systemic response results in tachycardia, a narrowing pulse pressure (due to peripheral vasoconstriction), and the shunting of blood away from the kidneys (causing severe oliguria) and the brain (causing restlessness and disorientation). Identifying these subtle, systemic physiological changes is critical for the practical nurse to escalate care and prevent irreversible shock.

Adım Adım Çözüm

1
Analyze the clinical scenario and client risk factors.
An 82-year-old client with acute pyelonephritis is at high risk for developing urosepsis and progressing into septic shock.
Understanding the primary diagnosis helps anticipate potential life-threatening complications.
2
Recall the physiological mechanisms of compensatory (early) shock.
The body attempts to maintain essential perfusion via sympathetic nervous system activation, leading to tachycardia, peripheral vasoconstriction, and blood shunting.
Recognizing early compensatory mechanisms allows for rapid intervention before shock becomes irreversible.
3
Evaluate each assessment finding against the criteria for systemic decompensation vs. expected localized infection symptoms.
Tachycardia with a narrow pulse pressure, new-onset altered mental status, and severe oliguria indicate failing systemic perfusion. Flank pain, mild fever, and cloudy urine are localized, expected symptoms of the primary infection.
Differentiating between expected disease manifestations and acute systemic deterioration is a core competency for prioritizing client safety.

Anahtar Kavram

Early Recognition of Compensatory Shock
Tahmini Süre:2m 0s
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Konular

Physiological Adaptation

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