While performing a clinical assessment on a client who underwent an open splenectomy four hours ago, the nurse reviews the electronic health record. The baseline vital signs recorded upon arrival to the surgical unit were: blood pressure 128/72 mm Hg, heart rate 76 beats/min, and respiratory rate 16 breaths/min. Which of the following current clinical findings should the nurse interpret as the earliest sign of impending physiological decompensation that necessitates immediate risk mitigation?
- A blood pressure of 110/86 mm Hg and a heart rate of 104 beats/minCevap
- BA total of 70 mL of urine collected in the indwelling catheter drainage bag over the preceding two hours
- CAn oral temperature of 37.9°C (100.2°F) accompanied by reports of incisional discomfort
- DSerosanguineous exudate visible on a 2-inch by 2-inch area of the primary abdominal dressing
Cevap
The finding of a blood pressure of 110/86 mm Hg and a heart rate of 104 beats/min provides the earliest indication of impending physiological decompensation.
The correct answer identifies a narrowing pulse pressure and mild tachycardia. The pulse pressure has decreased from 56 mm Hg at baseline to 24 mm Hg, and the heart rate has correspondingly increased. Because the spleen is a highly vascular organ, an open splenectomy carries a significant risk of postoperative hemorrhage. These subtle vital sign changes reflect the body's compensatory mechanisms (sympathetic nervous system activation causing vasoconstriction and tachycardia) in early hypovolemic shock, which requires immediate fluid resuscitation and provider notification to mitigate severe risk.
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Early Recognition of Hypovolemic Shock