A nurse is assessing a client who was admitted to the medical-surgical unit with severe hematemesis and melena. The nurse suspects the client is entering the early compensatory stage of hypovolemic shock. Which of the following assessment findings support this conclusion? Select all that apply.
- Restlessness and mild apprehensionCevap
- Heart rate of 118 beats/minCevap
- Pulse pressure decreasing from 45 mm Hg to 25 mm HgCevap
- DSystolic blood pressure dropping from 128 mm Hg to 86 mm Hg
- EArterial blood gas revealing a PaCO2 of 48 mm Hg
Cevap
The assessment findings that support the early compensatory stage of hypovolemic shock are restlessness and mild apprehension, a heart rate of 118 beats/min, and a pulse pressure decreasing from 45 mm Hg to 25 mm Hg.
In the early compensatory stage of hypovolemic shock, the body's baroreceptors detect a drop in intravascular volume and stimulate the sympathetic nervous system. This results in an increased heart rate (tachycardia) to maintain cardiac output, and peripheral vasoconstriction which raises diastolic blood pressure, leading to a narrowed pulse pressure. Additionally, subtle decreases in cerebral perfusion cause early neurological changes such as restlessness, anxiety, and mild apprehension.
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During the early compensatory stage of shock, the sympathetic nervous system activates to maintain cardiac output and blood pressure. Key indicators include tachycardia, narrowing pulse pressure, restlessness, and respiratory alkalosis, whereas profound hypotension occurs in later, progressive stages.