A client is recovering on the surgical unit 12 hours after a total abdominal hysterectomy. The nurse evaluates the client's vital sign trends over the past four hours. The heart rate has steadily risen from 82 to 118 beats per minute. The blood pressure has changed from 126/78 mm Hg to 112/90 mm Hg. The client is awake but appears restless and complains of intense thirst. Which action should the nurse implement first?
- Position the client flat in bed with the lower extremities elevated.Cevap
- BGuide the client through deep breathing exercises using an incentive spirometer.
- CProvide a dose of intravenous morphine to alleviate post-operative discomfort.
- DElevate the head of the bed to a high-Fowler's position to promote oxygenation.
Cevap
Position the client flat in bed with the lower extremities elevated.
The client's assessment findings—tachycardia, a narrowing pulse pressure, restlessness, and intense thirst—are classic indicators of the compensatory stage of hypovolemic shock. As intravascular volume decreases, the sympathetic nervous system triggers peripheral vasoconstriction, which raises the diastolic blood pressure and narrows the pulse pressure (in this case, from 48 mm Hg to 22 mm Hg). Positioning the client flat with the lower extremities elevated (modified Trendelenburg) promotes venous return from the legs to the core circulation, temporarily increasing cardiac output and brain perfusion while intravenous fluid resuscitation is prepared.
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Anahtar Kavram
Early identification and positional management of compensatory hypovolemic shock