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Zorluk: ZorPhysiological Adaptation

A nurse is monitoring a client who recently underwent endoscopic band ligation for bleeding esophageal varices. Which assessment findings should the nurse identify as early indicators of systemic physiological deterioration and impending hypovolemic shock? (Select all that apply.)

  1. New-onset restlessness and frequent, purposeless movementsCevap
  2. Urine output of 15 mL over the past hourCevap
  3. Respiratory rate increasing from 16 to 28 breaths per minuteCevap
  4. D
    A widening pulse pressure from 40 mmHg to 55 mmHg
  5. E
    Arterial blood gas values indicating uncompensated metabolic alkalosis
  6. F
    Client report of a scratchy throat and minor discomfort when swallowing

Cevap

The early indicators of impending hypovolemic shock include new-onset restlessness, decreased urine output (15 mL/hr), and increased respiratory rate (28 breaths/min).
In the early, compensatory stage of hypovolemic shock due to acute blood loss, the sympathetic nervous system activates to maintain cardiac output. This physiological adaptation includes shunting blood away from non-vital organs (causing oliguria), increasing respiratory drive to maximize oxygenation (tachypnea), and early signs of reduced cerebral perfusion (manifesting as restlessness, anxiety, or subtle agitation). Recognizing these subtle cues is critical for early intervention before profound cardiovascular collapse occurs.

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1
Analyze the client's clinical context.
The client is post-endoscopic band ligation for varices, placing them at extremely high risk for recurrent gastrointestinal hemorrhage and hypovolemic shock.
Establishing the primary physiological threat directs the focus to assessing hemodynamic stability and tissue perfusion.
2
Identify the compensatory mechanisms triggered during early (stage I/II) shock.
The body activates the sympathetic nervous system, leading to tachycardia, tachypnea, peripheral vasoconstriction, decreased renal perfusion, and altered cerebral oxygenation.
Early recognition relies on detecting these subtle compensatory shifts before a profound drop in blood pressure occurs.
3
Evaluate each assessment finding against anticipated shock physiology.
Restlessness (cerebral hypoxia), oliguria (renal conservation), and tachypnea (respiratory compensation) align with early shock. Widened pulse pressure, metabolic alkalosis, and a scratchy throat do not.
Differentiating between compensatory clinical signs and expected procedural side effects prevents failure to rescue.

Anahtar Kavram

Early Recognition of Hypovolemic Shock and Compensatory Mechanisms
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Konular

Physiological Adaptation

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