Clinical alerts sound simultaneously from the rooms of four clients on a medical-surgical ward. Upon quickly scanning the unit dashboard, the registered nurse should immediately proceed to the room of the client demonstrating which clinical picture?
- AA client with liver cirrhosis and ascites who has a respiratory rate of 22 breaths per minute and reports shortness of breath when lying supine
- BA client who is 24 hours post-laparoscopic cholecystectomy reporting right shoulder pain and an oral temperature of 99.4°F (37.4°C)
- A client with acute pancreatitis who has a heart rate of 128 beats per minute, a blood pressure of 88/54 mmHg, and new periumbilical ecchymosisCevap
- DA client with a newly inserted percutaneous endoscopic gastrostomy (PEG) tube who has a small amount of serosanguineous drainage on the peri-stomal dressing
Cevap
The client with acute pancreatitis demonstrating tachycardia, hypotension, and periumbilical ecchymosis (Cullen's sign) requires immediate intervention due to impending hemorrhagic shock.
The correct answer is the client with acute pancreatitis presenting with a heart rate of 128 beats per minute, a blood pressure of 88/54 mmHg, and new periumbilical ecchymosis. These findings indicate Cullen's sign and severe retroperitoneal bleeding, leading to hemorrhagic shock. According to the ABC (Airway, Breathing, Circulation) framework, circulatory collapse is an acute, life-threatening emergency that must be addressed immediately with fluid resuscitation and medical intervention.
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Anahtar Kavram
In clinical prioritization, clients experiencing unexpected, acute manifestations of airway, breathing, or circulatory compromise (such as hemorrhagic shock) must be assessed and treated before clients with chronic conditions or expected post-procedural findings.