A client is in suspected shock state from major trauma. Which parameters best indicate the adequacy of peripheral perfusion? Select all that apply.

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Shock is a life-threatening syndrome characterized by decreased perfusion and impaired cellular metabolism. A lack of perfusion at both the tissue and cellular level (anaerobic metabolism) occurs due to decreased cardiac output, ineffective blood flow, and inability to meet the body's demand for increased oxygen. Sustained hypoperfusion activates compensatory mechanisms (eg, neural, hormonal, biochemical) to maintain homeostasis and reverse the consequences of anaerobic metabolism. Shock will progress through 4 stages (initial, compensatory, progressive, irreversible). Early identification and intervention help to prevent stage progression. Adequacy of tissue perfusion in a client with shock syndrome and possible organ dysfunction is assessed by the level of consciousness, urine output, capillary refill, peripheral sensation, skin color, extremity temperature, and peripheral pulses. Capillary refill indicates adequacy of blood flow to the peripheral tissues. It is measured by the time taken for color (pink) to return to an external capillary bed (nail bed) after pressure is applied to cause blanching. In an adult, color should return in less than 3 seconds. Normal skin color and temperature are indicators of the adequacy of peripheral blood flow; these are usually within normal limits during the initial and compensatory stages of shock. (Option A) Apical pulse is a central pulse and does not indicate adequacy of peripheral tissue perfusion. (Option C) Lung sounds indicate the adequacy of ventilation and gas exchange, not peripheral tissue perfusion. (Option D) Pupillary response is an indicator of cerebral function, not peripheral tissue perfusion. Educational objective: The adequacy of blood flow to peripheral tissues is determined by measuring capillary refill and assessing skin color and temperature; these are usually within normal limits during the initial and compensatory stages of shock.

A Client Is in Suspected Shock State from Major Trauma