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Zorluk: OrtaPhysiological Adaptation

A nurse is caring for a client who is 4 hours postoperative following an abdominal hysterectomy. The client reports feeling slightly nauseous. The most recent vital signs are: temperature 37.2°C (99.0°F), heart rate 118 beats/min, respiratory rate 22 breaths/min, and blood pressure 104/78 mm Hg. The client's baseline blood pressure upon arrival at the surgical unit was 126/82 mm Hg. The abdominal surgical dressing is intact with a 2 cm area of serosanguineous drainage. Which of the following is the priority nursing action?

  1. Notify the healthcare provider and prepare for intravenous fluid resuscitation.Cevap
  2. B
    Administer the prescribed PRN antiemetic medication to relieve the client's nausea.
  3. C
    Elevate the head of the bed to a high Fowler's position to optimize respiratory effort.
  4. D
    Reinforce the surgical dressing and continue routine postoperative monitoring.

Cevap

The priority action is to notify the healthcare provider and prepare for intravenous fluid resuscitation.
The correct answer addresses the immediate life-threatening risk. The client is exhibiting an elevated heart rate (118 beats/min) and a narrowing pulse pressure (decreasing from 44 mm Hg to 26 mm Hg). These are classic early compensatory signs of hypovolemic or hemorrhagic shock. Recognizing these subtle vital sign changes is critical so that interventions, such as fluid resuscitation, can be initiated before the client decompensates further into severe hypotension and organ failure.

Adım Adım Çözüm

1
Analyze the vital sign trends by comparing the current readings to the client's baseline.
The heart rate has increased to 118 beats/min, and the pulse pressure has narrowed significantly from 44 mm Hg (126 - 82) to 26 mm Hg (104 - 78).
Subtle changes in vital signs, particularly a narrowing pulse pressure, are often the earliest indicators of physiological deterioration before frank hypotension occurs.
2
Identify the underlying complication indicated by the assessment data.
Tachycardia and a narrowing pulse pressure in a postoperative client are hallmark signs of early compensatory hypovolemic or hemorrhagic shock.
The body compensates for fluid or blood loss by increasing the heart rate and causing peripheral vasoconstriction, which disproportionately raises the diastolic blood pressure and narrows the pulse pressure.
3
Determine the priority nursing intervention based on the ABCs (Airway, Breathing, Circulation).
Prioritize interventions that address the circulatory collapse by preparing for fluid resuscitation and notifying the provider immediately.
Addressing the compromised circulation is the highest priority to prevent the client from progressing to uncompensated shock and organ failure.

Anahtar Kavram

Early recognition and prioritization of interventions for hypovolemic shock.
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Konular

Physiological Adaptation

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