The patient comes to the emergency department after suffering a bilateral traumatic amputation of his lower extremities. The physician orders normal serum albumin (Albuminar). The patient goes into shock. What will the best nursing assessment of this patient reveal?
1. B/P: 140/90 mmHg, P: 46, weak and irregular, R: 24, and shallow.
2. B/P: 50/0 mmHg, P: 126, weak and thready, R: 14, and shallow.
3. B/P: 80/20 mmHg, P: 122, weak and thready, R: 28, and shallow.
4. B/P: 130/88 mmHg, P: 90, bounding, R: 32, and shallow.
3
Rationale 1: A patient in shock will have a low blood pressure; the heart rate will be rapid, not slowed.
Rationale 2: A patient in shock will have rapid respirations; a respiratory rate of 14 is considered normal.
Rationale 3: The central problem with hypovolemic shock is the inability of the cardiovascular system to send sufficient blood to the vital organs, with the heart and brain being affected early in the progression of the disease. Assessing the patient's cardiovascular status will result in a blood pressure that is low; a heart rate that may be rapid with a weak, thready pulse; and breathing that is rapid and shallow.
Rationale 4: A patient in shock will have a low blood pressure and a rapid, weak, not bounding, pulse.
Global Rationale: The central problem with hypovolemic shock is the inability of the cardiovascular system to send sufficient blood to the vital organs, with the heart and brain being affected early in the progression of the disease. Assessing the patient's cardiovascular status will result in a blood pressure that is low; a heart rate that may be rapid with a weak, thready pulse; and breathing that is rapid and shallow. A patient in shock will have a low blood pressure and a rapid, weak, not bounding, pulse. A patient in shock will have rapid respirations; a respiratory rate of 14 is considered normal. A patient in shock will have a low blood pressure; the heart rate will be rapid, not slowed.
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