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Zorluk: ZorPhysiological Adaptation

A nurse is evaluating a client 12 hours after admission for full-thickness burns over 40% of the total body surface area. Which assessment findings indicate that the client is experiencing inadequate physiological adaptation and early hypovolemic (burn) shock? Select all that apply.

  1. Urine output averaging 15 mL/hr over the past two hoursCevap
  2. Unexplained restlessness and progressive agitationCevap
  3. Narrowing of the arterial pulse pressureCevap
  4. D
    Arterial blood gas indicating pH 7.47, PaCO2 32 mm Hg, HCO3 23 mEq/L
  5. E
    Bounding, full peripheral pulses in unburned extremities
  6. F
    Core body temperature of 100.6°F (38.1°C)

Cevap

The findings indicating early shock are a urine output of 15 mL/hr, unexplained restlessness and agitation, and a narrowing of the arterial pulse pressure.
In the emergent phase of a major burn, massive capillary leak leads to intravascular volume depletion. The correct findings represent early inadequate adaptation: urine output <30 mL/hr indicates poor renal perfusion; restlessness is an early sign of cerebral hypoxia; and a narrowing pulse pressure is a classic sympathetic compensatory response to decreased stroke volume.

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1
Analyze the clinical scenario
The client has massive burns (40% TBSA) in the emergent phase, placing them at extremely high risk for profound fluid shifts and hypovolemic (burn) shock.
Understanding the pathophysiology of the emergent burn phase directs the assessment toward recognizing signs of hypoperfusion.
2
Evaluate each option against the signs of compensatory shock
Identify findings that demonstrate decreased organ perfusion (oliguria, altered mentation) and sympathetic nervous system compensation (narrowing pulse pressure).
Early shock is characterized by compensatory mechanisms attempting to maintain core circulation at the expense of peripheral and renal perfusion.
3
Differentiate actual signs of shock from expected physiological responses to major trauma
Rule out respiratory alkalosis (expected from pain), bounding pulses (opposite of hypovolemia), and low-grade fever (expected inflammatory response).
Nurses must prioritize life-threatening decompensation over expected stress responses.

Anahtar Kavram

Early recognition of hypovolemic (burn) shock involves identifying subtle signs of hypoperfusion (oliguria, altered mental status) and compensatory mechanisms (narrowing pulse pressure), rather than solely relying on absolute hypotension.
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Physiological Adaptation

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