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Zorluk: KolayPhysiological Adaptation

A client is admitted to the medical unit with severe acute pancreatitis and is experiencing significant third-spacing of fluids. Which of the following data collection findings strongly indicate to the practical nurse that the client is developing hypovolemic shock? Select all that apply.

  1. Resting heart rate of 118 beats/minCevap
  2. Capillary refill time of 5 secondsCevap
  3. Sudden onset of mild confusion and restlessnessCevap
  4. D
    Client reports intense, sharp abdominal pain
  5. E
    Blood pressure reading of 145/88 mm Hg

Cevap

The findings indicating hypovolemic shock are a resting heart rate of 118 beats/min, a capillary refill time of 5 seconds, and a sudden onset of mild confusion and restlessness.
The correct options identify key systemic responses to decreased circulating blood volume. As intravascular fluid shifts into the interstitial space (third-spacing), the body compensates for the lack of volume by increasing the heart rate to maintain cardiac output. Peripheral vasoconstriction occurs to shunt blood to vital organs, resulting in delayed capillary refill. Additionally, decreased cerebral perfusion leads to early neurological changes, such as sudden confusion and restlessness.

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1
Analyze the client's condition and risk factors.
The client has acute pancreatitis with fluid third-spacing, which pulls fluid out of the vascular space, creating a high risk for hypovolemic shock.
Understanding the pathophysiology of fluid shifts directs the nurse to look for specific signs of decreased circulating blood volume.
2
Evaluate the options for signs of compromised circulation and perfusion.
Tachycardia, delayed capillary refill (greater than 3 seconds), and neurological changes (confusion/restlessness) are identified as direct circulatory failure signs.
These findings reflect the body's compensatory mechanisms (increased heart rate, peripheral vasoconstriction) and the consequences of poor organ perfusion (cerebral hypoxia).
3
Differentiate expected local disease symptoms from systemic life-threatening complications.
The abdominal pain is identified as an expected local symptom of pancreatitis, while the elevated blood pressure contradicts the hemodynamics of shock.
Separating expected baseline symptoms from acute physiological deterioration ensures correct ABC prioritization.

Anahtar Kavram

Early recognition of physiological compensatory mechanisms in hypovolemic shock
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Konular

Physiological Adaptation

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