Physiological Adaptation Q 36
A client has 15% blood loss. Which of the following nursing assessment findings indicates hypovolemic shock?
A. Systolic blood pressure less than 90mm Hg
B. Pupils unequally dilated
C. Respiratory rate of 4 breath/min
D. Pulse rate less than 60 bpm
Correct Answer: A. Systolic blood pressure less than 90mm Hg
Typical signs and symptoms of hypovolemic shock includes systolic blood pressure of less than 90 mm Hg. The first changes in vital signs seen in hypovolemic shock include an increase in diastolic blood pressure with narrowed pulse pressure. As volume status continues to decrease, systolic blood pressure drops. As a result, oxygen delivery to vital organs is unable to meet oxygen demand.
Option B: Unequally dilated pupils refer to anisocoria. Acute onset should be considered an emergency because it may be due to brain mass lesions which cause oculomotor nerve palsy. Anisocoria is a condition characterized by unequal pupil size. The etiology of anisocoria is complex, ranging from benign to potentially life-threatening causes. There are many pathways involved in pupil size. Some potential etiologies of anisocoria include systemic drug use, topical ophthalmic drug use, headaches, and autonomic ganglion pathology.
Option C: This indicates a very low respiratory rate or bradypnea. Tachypnea is seen in clients with class II hemorrhage (loss of 15-30%). Similar to examining pulse pressure variation, measuring respiratory variation in inferior vena cava diameter as a measure of volume responsiveness has only been validated in patients without spontaneous breaths or arrhythmias.
Option D: The cardiovascular system initially responds to hypovolemic shock by increasing the heart rate, increasing myocardial contractility, and constricting peripheral blood vessels. Patients with volume depletion may complain of thirst, muscle cramps, and/or orthostatic hypotension. Severe hypovolemic shock can result in mesenteric and coronary ischemia that can cause abdominal or chest pain. Agitation, lethargy, or confusion may result from brain malperfusion.