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Zorluk: OrtaPhysiological Adaptation

A 30-year-old client is admitted to the medical-surgical unit with acute pancreatitis. The client is receiving continuous intravenous normal saline at 100 mL/hr. During a routine check, the client appears restless and anxious. Current vital signs are: pulse 124 beats per minute, blood pressure 88/54 mm Hg, and respirations 24 breaths per minute. Total urine output over the previous 4 hours is 55 mL.

What is the most appropriate initial action for the practical nurse to take?

  1. A
    Provide the as-needed intramuscular analgesic, attributing the elevated heart rate and restlessness to abdominal discomfort.
  2. Position the client flat in bed with their lower extremities elevated and immediately report the findings to the supervising nurse.Cevap
  3. C
    Reduce the rate of the continuous intravenous fluid infusion because the client is exhibiting signs of decreased renal clearance.
  4. D
    Record the assessment findings in the chart, recognizing that mild hypotension and tachycardia are expected physiological responses to pancreatitis.

Cevap

Position the client flat in bed with their lower extremities elevated and immediately report the findings to the supervising nurse.
The client is demonstrating classic signs of hypovolemic shock (restlessness, tachycardia, hypotension, and oliguria) secondary to fluid shifting (third-spacing) caused by acute pancreatitis. Placing the client flat with elevated legs (passive leg raise) promotes venous return to vital organs. Immediately escalating the situation to the supervising nurse ensures the client receives prompt medical interventions, such as aggressive fluid resuscitation.

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1
Analyze the clinical data provided in the scenario.
The client has tachycardia (124 bpm), hypotension (88/54 mm Hg), tachypnea (24/min), oliguria (55 mL over 4 hours, which is less than the minimum 30 mL/hr), and restlessness.
Identifying abnormal findings is the first step in clinical judgment.
2
Correlate the findings with the underlying pathophysiology of acute pancreatitis.
These vital signs represent hypovolemic shock, a serious complication of pancreatitis caused by significant fluid shifting (third-spacing) into the peritoneal cavity.
Understanding the disease process helps distinguish expected symptoms from life-threatening emergencies.
3
Determine the priority nursing action within the practical nurse's scope of practice.
The priority is to support circulation (ABCs) by elevating the legs to increase venous return and immediately escalating the situation to the registered nurse or provider for advanced interventions.
Circulatory collapse takes precedence over pain management or routine documentation, and rapid escalation is required for critical instability.

Anahtar Kavram

Early Recognition and Prioritization of Hypovolemic Shock
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Konular

Physiological Adaptation

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