Shift report is completed for a client who underwent an exploratory laparotomy 24 hours ago for a severe bowel obstruction. Current assessment reveals a heart rate of 124 beats per minute, a respiratory rate of 28 breaths per minute, and a blood pressure of 96/68 mm Hg (a decrease from 118/74 mm Hg four hours ago). The client's extremities are cool to the touch, and urine output has been 45 mL over the past three hours. Arterial blood gas (ABG) analysis on room air indicates a pH of 7.28, of 30 mm Hg, of 15 mEq/L, and of 64 mm Hg. Based on these findings, which of the following nursing actions are appropriate? (Select all that apply.)
- Initiate a rapid intravenous infusion of an isotonic crystalloid solution.Cevap
- Apply supplemental oxygen to maximize tissue perfusion.Cevap
- CAdminister intravenous sodium bicarbonate to reverse the respiratory acidosis.
- DDocument the findings as a typical sympathetic nervous system response to postoperative pain.
- EComplete the scheduled sterile abdominal dressing change prior to notifying the healthcare provider.
Cevap
The appropriate actions are to initiate a rapid intravenous infusion of an isotonic crystalloid solution and apply supplemental oxygen.
The correct actions prioritize the ABCs (Airway, Breathing, Circulation) in a client demonstrating signs of early shock. Tachycardia, a narrowing pulse pressure, oliguria, and metabolic acidosis indicate inadequate tissue perfusion. Administering supplemental oxygen maximizes the oxygen-carrying capacity, while rapid isotonic fluid administration restores intravascular volume.
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Anahtar Kavram
Early Recognition and Management of Shock