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Zorluk: OrtaPhysiological Adaptation

During afternoon rounds on a surgical unit, a client who had a partial colectomy two days ago reports feeling increasingly restless and unable to get comfortable. The assessment reveals a temperature of 98.4°F (36.9°C), a heart rate of 114 beats per minute, a blood pressure of 104/84 mm Hg, and a respiratory rate of 22 breaths per minute. The client's skin is cool to the touch and peripheral pulses are weak. Which of the following is the priority nursing action?

  1. Examine the surgical incision site and the drainage collection device for signs of active bleedingCevap
  2. B
    Administer the client's prescribed as-needed intravenous analgesic for restlessness
  3. C
    Direct the unlicensed assistive personnel to repeat the vital sign measurements in 15 minutes
  4. D
    Elevate the head of the bed to a high-Fowler's position to ease the slightly elevated respiratory rate

Cevap

The highest priority action is to examine the surgical incision site and drainage collection device for signs of active bleeding.
The client is exhibiting classic signs of the compensatory stage of hypovolemic shock, which include a narrowing pulse pressure (20 mm Hg), tachycardia, tachypnea, unexplained restlessness, and cool skin due to peripheral vasoconstriction. Because this client is only two days postoperative, internal hemorrhage is a high-risk complication. The priority is to assess for the source of bleeding (such as the incision and drains) so that the healthcare provider can be alerted and fluid resuscitation can begin.

Adım Adım Çözüm

1
Analyze the client's vital signs and physical assessment findings.
The client presents with tachycardia (114 bpm), a narrow pulse pressure (104 - 84 = 20 mm Hg), tachypnea (22 breaths/min), restlessness, and cool skin.
Identifying abnormal physiological trends is the first step in recognizing clinical deterioration.
2
Correlate the findings with potential postoperative complications.
The combination of these specific signs strongly indicates the compensatory stage of hypovolemic shock, likely due to internal hemorrhage.
The sympathetic nervous system activates to maintain cardiac output through vasoconstriction (narrow pulse pressure, cool skin) and tachycardia.
3
Determine the highest priority nursing intervention.
The nurse must immediately assess for the source of the suspected bleeding to initiate appropriate medical management.
According to the ABCs (Airway, Breathing, Circulation), addressing a severe circulation deficit takes precedence over routine symptom management or delegation.

Anahtar Kavram

Recognition of Compensatory Hypovolemic Shock
Tahmini Süre:1m 0s
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Physiological Adaptation

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