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Zorluk: Çok zorReduction of Risk Potential

A 3535-year-old client is 66 hours post-operative following an open reduction and internal fixation (ORIF) of a severe pelvic fracture. The client is receiving a continuous epidural infusion of bupivacaine and fentanyl. The nurse collects the following assessment data:

AssessmentFinding
Heart rate114114 beats/minute
Blood pressure106/82 mm Hg106/82 \text{ mm Hg}
Respiratory rate2222 breaths/minute
Arterial Blood GaspH 7.317.31, PaCO2\text{PaCO}_2 34 mm Hg34 \text{ mm Hg}, HCO3−\text{HCO}_3^- 16 mEq/L16 \text{ mEq/L}
Urine output35 mL35 \text{ mL} over the past 22 hours
SensoriumMildly restless and reports intense thirst

Which of the following actions should the nurse perform immediately to reduce the risk of further physiological deterioration?

  1. Position the client flat and prepare to initiate rapid intravenous fluid resuscitation with isotonic crystalloidsCevap
  2. B
    Elevate the head of the bed to a high-Fowler's position to optimize diaphragmatic excursion and improve alveolar ventilation
  3. C
    Request a prescription for intravenous sodium bicarbonate to correct the client's uncompensated respiratory acidosis
  4. D
    Document these vital signs as a normal physiological stress response to severe trauma and continue routine monitoring

Cevap

Position the client flat and prepare to initiate rapid intravenous fluid resuscitation with isotonic crystalloids.
The client's assessment data strongly indicate compensatory hypovolemic (hemorrhagic) shock, a major risk following pelvic trauma. In this early stage, the systolic blood pressure may appear deceptively normal due to intense peripheral vasoconstriction, but the narrow pulse pressure (24 mm Hg24 \text{ mm Hg}) and lactic acidosis (metabolic acidosis) reveal severe tissue hypoperfusion. Positioning the client flat maximizes venous return to the heart, and rapid isotonic crystalloid administration is the immediate priority to restore intravascular volume.

Adım Adım Çözüm

1
Analyze the client's vital signs and hemodynamic parameters.
The pulse pressure is extremely narrow (106−82=24 mm Hg106 - 82 = 24 \text{ mm Hg}), accompanied by tachycardia (114 bpm114 \text{ bpm}) and severe oliguria (17.5 mL/hr17.5 \text{ mL/hr}).
A narrow pulse pressure combined with tachycardia is a cardinal sign of compensatory hypovolemic shock, even when the systolic pressure appears relatively stable above 100 mm Hg100 \text{ mm Hg}.
2
Evaluate the arterial blood gas (ABG) results and clinical presentation.
The ABG reveals an uncompensated metabolic acidosis (pH 7.317.31, low HCO3−\text{HCO}_3^- 16 mEq/L16 \text{ mEq/L}). The client is restless and thirsty.
In the context of severe pelvic trauma, this metabolic acidosis reflects lactic acid accumulation due to severe tissue hypoperfusion. Restlessness and thirst are classic indicators of cellular hypoxia and volume depletion.
3
Determine the priority nursing intervention to reduce physiological risk.
The highest priority is to optimize venous return by positioning the client flat (supine) and preparing for rapid intravascular volume expansion.
Immediate fluid resuscitation reverses the hypovolemic state and prevents progression to irreversible shock and multi-organ failure.

Anahtar Kavram

Recognizing early compensatory hypovolemic shock via narrow pulse pressure and metabolic acidosis, and intervening promptly with volume resuscitation.
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Konular

Reduction of Risk Potential

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