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Zorluk: ZorReduction of Risk Potential

A client with a history of cirrhosis is being monitored 22 hours after a large-volume paracentesis in which 66 liters of ascitic fluid were removed. The client's current vital signs are: blood pressure 94/7894/78 mm Hg, heart rate 116116 bpm, and respiratory rate 2424/min. An arterial blood gas (ABG) analysis reveals a pH of 7.297.29, a PaCO2PaCO_2 of 3131 mm Hg, and an HCO3−HCO_3^- of 1515 mEq/L. The unlicensed assistive personnel (UAP) is preparing to assist the client into a high-Fowler's position to eat a meal. Which action should the nurse take first to reduce the risk of a severe complication?

  1. A
    Administer the client's scheduled dose of oral metoprolol to correct the tachycardia and decrease cardiac workload
  2. B
    Administer a prescribed dose of intravenous sodium bicarbonate to correct the client's uncompensated respiratory acidosis
  3. Stop the UAP and place the client in a supine position with the lower extremities elevatedCevap
  4. D
    Assist the UAP in raising the head of the bed to a high-Fowler's position to maximize diaphragmatic excursion

Cevap

The nurse must immediately stop the UAP from elevating the head of the bed and instead place the client in a supine position with the lower extremities elevated to address the impending hypovolemic shock.
The client is demonstrating early signs of hypovolemic shock (narrow pulse pressure, compensatory tachycardia) and poor tissue perfusion (metabolic acidosis), a known risk called post-paracentesis circulatory dysfunction. Placing the client in a high-Fowler's position will trap blood in the lower extremities and splanchnic bed, decreasing venous return and potentially precipitating immediate cardiovascular collapse. The nurse must immediately intervene to position the client supine with legs elevated to promote venous return to the vital organs.

Adım Adım Çözüm

1
Analyze the client's vital signs and clinical context.
The removal of 66 liters of fluid places the client at high risk for fluid shifts. The narrow pulse pressure (1616 mm Hg) and tachycardia (116116 bpm) are early indicators of post-paracentesis circulatory dysfunction (hypovolemic shock).
Recognizing early shock is critical before profound hypotension occurs.
2
Interpret the arterial blood gas (ABG) values.
The ABG shows a low pH (7.297.29) and low HCO3−HCO_3^- (1515 mEq/L), indicating metabolic acidosis. The PaCO2PaCO_2 (3131 mm Hg) is appropriately low as the lungs attempt to compensate.
Metabolic acidosis in this context is likely lactic acidosis caused by poor tissue perfusion, further confirming a state of shock.
3
Evaluate the proposed action of placing the client in a high-Fowler's position.
A high-Fowler's position uses gravity to pool blood in the splanchnic bed and lower extremities, significantly decreasing venous return.
Decreased venous return will worsen the client's already compromised cardiac output.
4
Determine the priority nursing intervention to reduce risk.
The nurse must intervene to place the client flat with elevated legs (modified Trendelenburg).
This position optimizes venous return to the heart and brain, temporarily stabilizing hemodynamics while fluid resuscitation (e.g., albumin) is prepared.

Anahtar Kavram

Early recognition and positional management of hypovolemic shock
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Konular

Reduction of Risk Potential

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