Question

A woman is admitted to the emergency room with bleeding from a stab wound in the right chest area. Which assessment findings would the nurse interpret as indicating the initial phase of hypovolemic shock? Mark all that apply. A. Increased hematocrit B. Narrowed pulse pressure C. Elevated heart rate D. Oxygen saturation of less than \(80 \%\) E. Increased rate and depth of respiration F. Absent superficial peripheral pulses G. Slowed capillary refill

Short answer

The assessment findings indicating the initial phase of hypovolemic shock are B) Narrowed pulse pressure, C) Elevated heart rate, and E) Increased rate and depth of respiration.

Step-by-step solution

Understanding Hypovolemic Shock

Hypovolemic shock is a condition that occurs when a person loses more than 20 percent (one-fifth) of the body's blood or fluid supply. This severe fluid loss makes it impossible for the heart to pump a sufficient amount of blood to the body, which can lead to organs failing. The initial phase of hypovolemic shock includes the body's immediate response to the decrease in blood volume.

Identifying the Initial Phase Assessment Findings

In the initial phase of hypovolemic shock, because the blood volume is reduced, the body will attempt to compensate by constricting blood vessels to maintain blood pressure, and by increasing heart rate to improve cardiac output. The choices indicating initial phase assessment findings typically include narrowed pulse pressure (due to constriction of blood vessels), elevated heart rate and increased respiration rate and depth as the body tries to supply more oxygen to tissues.

Marking the Correct Options

Given the physiological responses explained previously, the correct assessment findings that indicate the initial phase of hypovolemic shock are: B - Narrowed pulse pressure, since the systolic pressure remains high while the diastolic pressure increases due to peripheral vasoconstriction; C - Elevated heart rate, as a compensatory mechanism to maintain cardiac output; and E - Increased rate and depth of respiration, as the body tries to supply more oxygen to the tissues.

Excluding Incorrect Options

Option A - Increased hematocrit may eventually occur due to a decrease in plasma volume, but it is not a primary sign of initial hypovolemic shock. Option D - Oxygen saturation of less than 80% is not specific to the initial stage of hypovolemic shock and is a severe finding that indicates significant oxygen deprivation. Option F - Absent superficial peripheral pulses and option G - Slowed capillary refill are signs of later and more severe stages of shock when compensatory mechanisms have failed.

Key concepts

NCLEX-RN Examination Preparation

When preparing for the NCLEX-RN examination, understanding hypovolemic shock is crucial, as it's a common emergency scenario covered in the test. The examination aims to validate your knowledge and skills necessary to provide safe and effective nursing care.
Start by familiarizing yourself with the fundamentals of shock, the pathophysiology behind it, and the body's response to the acute loss of blood or fluids. Focus on the compensatory mechanisms such as narrowed pulse pressure, elevated heart rate, and increased respiratory rate as initial indicators of hypovolemic shock.
Use study guides and practice exams to reinforce your knowledge on shock management, and remember to review NCLEX-style questions that often present scenarios requiring assessment and critical thinking. Through methodical study and understanding of core concepts, you'll be better positioned to handle related questions on your exam.

Nursing Shock Management

In nursing shock management, recognizing the early signs of hypovolemic shock can be life-saving. Assessing the patient's cardiovascular status is a fundamental step.

Signs of Compensatory Stage

• Narrowed pulse pressure indicating vasoconstriction.
• Elevated heart rate as the body attempts to maintain cardiac output.
• Increased respiratory rate and depth to enhance oxygen delivery to tissues.

Remember that hemodynamic monitoring is essential. Interventions may include fluid replacement and blood transfusions, guided by the assessment findings. It is also important to prepare for potential medication administration to support heart function and blood pressure. Continuous education in shock management strategies, such as Advanced Cardiac Life Support (ACLS), can improve patient outcomes during such critical situations.

Emergency Nursing Care

Emergency nursing care for a patient with hypovolemic shock requires swift action to prevent progression to more severe stages of shock. After the initial assessment, you should:

Immediate Nursing Interventions

• Maintain airway, breathing, and circulation (the ABCs).
• Initiate oxygen therapy to counteract hypoxia.
• Establish intravenous access for fluid resuscitation.

Continuous monitoring of vital signs, oxygen saturation, and mental status is crucial to detect changes in the patient's condition. Moreover, the nursing care plan should include regular evaluation of interventions' effectiveness and readiness to adapt the care plan as the patient's status evolves. Education on emergency nursing care emphasizes staying calm, thinking critically, and systematically prioritizing interventions.