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Zorluk: OrtaReduction of Risk Potential

A nurse is evaluating a 54-year-old client who is 4 hours post-operative following a right partial nephrectomy for renal cell carcinoma. The client's baseline vital signs upon arrival to the surgical unit were: blood pressure 128/74 mm Hg, heart rate 76 beats/min, and respiratory rate 16 breaths/min. Which of the following assessment findings is the EARLIEST indicator that the client is developing hemorrhagic shock?

  1. A blood pressure of 122/88 mm Hg, a heart rate of 114 beats/min, and new-onset restlessness.Cevap
  2. B
    A blood pressure of 86/52 mm Hg, a heart rate of 128 beats/min, and cold, mottled skin.
  3. C
    Arterial blood gas values showing a pH of 7.38, PaCO2 of 39 mm Hg, and HCO3 of 24 mEq/L.
  4. D
    An oral temperature of 99.4°F (37.4°C) and 40 mL of urine output over the past hour.

Cevap

A blood pressure of 122/88 mm Hg, a heart rate of 114 beats/min, and new-onset restlessness.
In the early compensatory stage of hemorrhagic shock, the body attempts to maintain cardiac output and tissue perfusion. Epinephrine and norepinephrine release leads to an increased heart rate (tachycardia) and peripheral vasoconstriction. This vasoconstriction raises the diastolic blood pressure while the systolic pressure remains relatively stable, resulting in a narrowed pulse pressure. Additionally, early cerebral hypoxia manifests as restlessness or anxiety.

Adım Adım Çözüm

1
Analyze the client's baseline vital signs.
The baseline blood pressure is 128/74 mm Hg (pulse pressure of 54 mm Hg) and the baseline heart rate is 76 beats/min.
Establishing a baseline is necessary to identify significant postoperative trends and deviations.
2
Compare the assessment findings in each option to the baseline and clinical expectations.
The finding of blood pressure 122/88 mm Hg, heart rate 114, and restlessness shows a narrowed pulse pressure (34 mm Hg) and new-onset tachycardia.
This comparison identifies the physiological changes associated with the early compensatory stage of shock.
3
Differentiate between early and late signs of shock.
Hypotension (blood pressure 86/52 mm Hg) is identified as a late sign, while narrowing pulse pressure, tachycardia, and restlessness are confirmed as the earliest indicators.
The question explicitly asks for the EARLIEST indicator of hemorrhagic shock.

Anahtar Kavram

Early indicators of hemorrhagic and hypovolemic shock (Compensatory Stage)
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Konular

Reduction of Risk Potential

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