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Zorluk: Çok zorPhysiological Adaptation

A nurse is caring for a client who was admitted to the trauma intensive care unit 44 hours ago following a high-speed motor vehicle collision. The client sustained a complete T2 spinal cord transection and a severe pelvic fracture.

Initial admission vital signs:
- Blood pressure: 94/60 mmHg94/60 \text{ mmHg}
- Heart rate: 58 bpm58 \text{ bpm}
- Respiratory rate: 18 breaths/min18 \text{ breaths/min}
- The client's skin was warm and dry below the chest.

Current assessment findings (44 hours later):
- Blood pressure: 70/40 mmHg70/40 \text{ mmHg}
- Heart rate: 64 bpm64 \text{ bpm}
- Respiratory rate: 28 breaths/min28 \text{ breaths/min}
- Urine output: 10 mL10 \text{ mL} over the past 22 hours
- Skin is now pale and diaphoretic above the level of injury.
- Arterial Blood Gas (ABG): pH 7.267.26, PaCO2\text{PaCO}_2 34 mmHg34 \text{ mmHg}, PaO2\text{PaO}_2 88 mmHg88 \text{ mmHg}, HCO3−\text{HCO}_3^- 15 mEq/L15 \text{ mEq/L}

Which of the following is the priority nursing action?

  1. Prepare to administer a rapid transfusion of packed red blood cells.Cevap
  2. B
    Initiate a prescribed continuous intravenous infusion of norepinephrine.
  3. C
    Administer a prescribed intravenous dose of sodium bicarbonate.
  4. D
    Perform a comprehensive neurological examination to assess for ascending edema.

Cevap

Prepare to administer a rapid transfusion of packed red blood cells.
The client is experiencing severe hemorrhagic shock secondary to the pelvic fracture, which is being masked by the concurrent T2 spinal cord injury. Normally, hemorrhagic shock triggers a massive sympathetic response resulting in significant tachycardia. However, a spinal cord transection at T2 blocks the sympathetic cardiac accelerator nerves (T1-T4), preventing the heart rate from elevating appropriately. The nurse must recognize the other critical indicators of profound hypoperfusion: a severe drop in blood pressure, extreme oliguria, and uncompensated metabolic acidosis (indicated by the low pH and HCO3−\text{HCO}_3^-). Because the client has an 'empty tank' from blood loss, volume resuscitation with blood products is the absolute priority to restore oxygen-carrying capacity and tissue perfusion.

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1
Analyze the baseline and current vital signs in the context of the client's injuries.
The client has profound hypotension (70/40 mmHg70/40 \text{ mmHg}), severe oliguria (10 mL10 \text{ mL} in 22 hours), and is unable to mount a tachycardic response (64 bpm64 \text{ bpm}) due to the T2 spinal cord transection.
Recognizing the physiological limitations caused by a high thoracic spinal cord injury is essential to accurately interpret the absence of classic shock signs like tachycardia.
2
Interpret the Arterial Blood Gas (ABG) results.
The ABG shows an uncompensated metabolic acidosis (pH 7.267.26, HCO3−\text{HCO}_3^- 15 mEq/L15 \text{ mEq/L}), likely due to elevated lactic acid from systemic hypoperfusion.
Metabolic acidosis in a trauma client with a pelvic fracture strongly indicates severe internal bleeding and tissue ischemia.
3
Prioritize nursing interventions based on the ABCs (Airway, Breathing, Circulation).
The client is in uncompensated hemorrhagic shock, masked by neurogenic shock. Immediate volume resuscitation with blood products is the highest priority.
Restoring circulating blood volume and oxygen-carrying capacity is the only way to reverse the lethal cycle of hemorrhagic shock.

Anahtar Kavram

Identifying masked hemorrhagic shock in clients with high thoracic or cervical spinal cord injuries.
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Konular

Physiological Adaptation

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