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Zorluk: Çok zorPhysiological Adaptation

A client is admitted to the medical unit with a history of peptic ulcer disease and reports of passing dark, tarry stools for the past two days. The client is currently resting in a supine position.

Vital signs upon admission (3 hours ago): Blood pressure 138/80138/80 mm Hg, heart rate 7878 beats/min, respiratory rate 1414 breaths/min.

Current assessment findings:
- Blood pressure 112/84112/84 mm Hg
- Heart rate 112112 beats/min
- Respiratory rate 2424 breaths/min
- SpO 2_2 96%96\% on room air
- The client reports feeling restless and slightly lightheaded.
- Arterial Blood Gas (ABG): pH 7.497.49, PaCO 2_2 2929 mm Hg, PaO 2_2 9292 mm Hg, HCO 3−_3^- 2323 mEq/L

Based on these findings, which of the following is the priority nursing intervention?

  1. A
    Coach the client to perform slow, diaphragmatic breathing exercises.
  2. B
    Elevate the head of the bed to 90 degrees to facilitate optimal lung expansion.
  3. Initiate a rapid bolus of the prescribed intravenous isotonic crystalloid solution.Cevap
  4. D
    Administer a prescribed PRN dose of intravenous lorazepam for acute restlessness.

Cevap

The priority intervention is to initiate a rapid bolus of the prescribed intravenous isotonic crystalloid solution.
The client is exhibiting signs of compensatory (early) hemorrhagic shock due to an upper gastrointestinal bleed. Although the systolic blood pressure remains >100>100 mm Hg, the narrowing pulse pressure (dropping from 5858 mm Hg to 2828 mm Hg), tachycardia, tachypnea, and restlessness are hallmark indicators of sympathetic nervous system activation in response to volume depletion. The immediate priority is to restore intravascular volume and cardiac output by administering isotonic crystalloid fluids.

Adım Adım Çözüm

1
Analyze the vital sign trends to identify physiological changes.
The pulse pressure has narrowed from 5858 mm Hg to 2828 mm Hg, accompanied by new-onset tachycardia (112112 bpm) and tachypnea (2424 breaths/min).
A narrowing pulse pressure is one of the earliest signs of compensatory shock, preceding a drop in systolic blood pressure.
2
Interpret the Arterial Blood Gas (ABG) values.
The ABG indicates uncompensated respiratory alkalosis (pH 7.497.49, PaCO 2_2 2929 mm Hg).
In early shock, sympathetic nervous system activation and tissue hypoxia trigger hyperventilation, blowing off carbon dioxide.
3
Evaluate the clinical symptoms in the context of the medical history.
The client with a suspected gastrointestinal bleed is exhibiting restlessness and lightheadedness.
These are early neurological indicators of decreased cerebral perfusion caused by hypovolemia.
4
Determine the highest priority nursing intervention.
Administering isotonic crystalloid fluids is selected as the first action.
Restoring intravascular volume is the critical first step in managing hemorrhagic shock and preventing cardiovascular collapse.

Anahtar Kavram

Early recognition and fluid resuscitation in compensatory hemorrhagic shock
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Konular

Physiological Adaptation

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