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Zorluk: OrtaPhysiological Adaptation

The nurse receives the shift report for four clients on a medical-surgical unit. Which client should the nurse assess first?

  1. A client with a history of gastrointestinal bleeding who has a blood pressure of 108/86 mm Hg, a heart rate of 112 bpm, and new-onset restlessness.Cevap
  2. B
    A client with chronic bronchitis who has an arterial blood gas showing pH 7.37, PaCO2 54 mm Hg, and HCO3 30 mEq/L.
  3. C
    A client 24 hours post-laparoscopic cholecystectomy who reports right shoulder pain and has a temperature of 37.7°C (99.9°F).
  4. D
    A client receiving a continuous intravenous heparin infusion for a deep vein thrombosis who has an activated partial thromboplastin time (aPTT) of 70 seconds.

Cevap

The client with a history of gastrointestinal bleeding who has a blood pressure of 108/86 mm Hg, a heart rate of 112 bpm, and new-onset restlessness.
The correct answer identifies a client experiencing early compensatory hypovolemic (hemorrhagic) shock. Normal pulse pressure is 30 to 50 mm Hg. This client has a narrowed pulse pressure of 22 mm Hg (108 - 86 = 22). As intravascular volume is lost, peripheral vasoconstriction increases the diastolic blood pressure, narrowing the gap between systolic and diastolic values. The compensatory tachycardia (112 bpm) and early signs of cerebral hypoxia (new-onset restlessness) indicate the client is actively deteriorating and requires immediate intervention.

Adım Adım Çözüm

1
Analyze the vital signs of the client with a gastrointestinal bleed.
The pulse pressure is narrow (108 - 86 = 22 mm Hg), heart rate is elevated (112 bpm), and the client is restless.
Identifying subtle vital sign changes is critical. Vasoconstriction narrows the pulse pressure as the body compensates for volume loss, and restlessness indicates early cerebral hypoxia.
2
Evaluate the arterial blood gas (ABG) for the client with chronic bronchitis.
The pH is normal (7.37), but PaCO2 (54 mm Hg) and HCO3 (30 mEq/L) are elevated.
This represents fully compensated respiratory acidosis, an expected baseline state for a client with chronic lung disease, and does not require urgent action.
3
Assess the post-operative findings for the client who had a laparoscopic cholecystectomy.
Right shoulder pain and a low-grade temperature (37.7°C) are present.
Carbon dioxide used to inflate the abdomen during surgery irritates the phrenic nerve, causing referred shoulder pain. Mild fever is a normal surgical inflammatory response.
4
Interpret the aPTT laboratory value for the client on a continuous heparin infusion.
The aPTT is 70 seconds.
The normal therapeutic goal for heparin is 1.5 to 2.5 times the baseline (typically 45-80 seconds). A value of 70 seconds is therapeutic and safe.
5
Compare all client presentations to determine the highest priority.
The client with the gastrointestinal bleed is the most unstable.
Using the ABCs (Airway, Breathing, Circulation) prioritization framework, the client demonstrating early signs of hypovolemic shock represents an immediate, life-threatening circulation issue.

Anahtar Kavram

Early Signs of Hypovolemic Shock and Prioritization
Tahmini Süre:1m 30s
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Konular

Physiological Adaptation

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