A 28-year-old client is admitted to the trauma unit after sustaining a closed pelvic fract… — NCLEX-RN

A $28$ -year-old client is admitted to the trauma unit after sustaining a closed pelvic fracture in a motorcycle collision. The nurse is monitoring the client for potential complications. Which of the following assessment findings suggest early physiological decompensation and require immediate intervention? (Select all that apply.)

A gradual increase in resting heart rate from $82$ to $118\text{ beats/min}$ Cevap
A narrowing of the pulse pressure from $45\text{ mmHg}$ to $22\text{ mmHg}$ Cevap
The development of new-onset restlessness and mild confusionCevap
D
A total urine output of $135\text{ mL}$ collected over the past three hours
E
Client reports localized pelvic pain rated as an $8$ on a $0$ to $10$ pain scale
F
A mild temperature elevation to $37.4^\circ\text{C}$ ( $99.3^\circ\text{F}$ )

Cevap

The correct findings that suggest early physiological decompensation are the gradual increase in resting heart rate, the narrowing of the pulse pressure, and the development of new-onset restlessness and mild confusion.

Pelvic fractures pose a high risk for severe internal bleeding and hypovolemic shock. Early signs of hypovolemic shock include a compensatory increase in heart rate (tachycardia) to maintain cardiac output, a narrowing pulse pressure (due to peripheral vasoconstriction raising the diastolic pressure), and early changes in the level of consciousness (such as restlessness, anxiety, or mild confusion) due to decreased cerebral perfusion. Identifying these subtle, early signs allows for prompt intervention before irreversible decompensation occurs.

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Analyze the client's clinical presentation and associated risk factors.

The client has a closed pelvic fracture, which carries a very high risk for massive internal hemorrhage and subsequent hypovolemic shock.

Pelvic fractures can easily lacerate major regional blood vessels, leading to significant, concealed internal blood loss.

Evaluate each assessment finding to differentiate between expected post-trauma responses and early signs of shock.

Tachycardia, a narrowing pulse pressure, and altered mental status are identified as abnormal, compensatory responses to volume loss.

During early hypovolemia, the sympathetic nervous system triggers an increased heart rate and peripheral vasoconstriction (narrowing the pulse pressure) to maintain cardiac output, while early brain hypoxia manifests as restlessness.

Identify the expected findings that do not represent an immediate life-threatening priority.

Severe localized pain, a mild temperature elevation, and a urine output of

45\text{ mL/hr}

are recognized as expected or adequate findings.

Prioritization requires distinguishing between stable, expected inflammatory/traumatic responses and subtle hemodynamic indicators of instability.

Anahtar Kavram

Early Detection of Hypovolemic Shock in Trauma

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