The nurse is caring for a client in the immediate postoperative period following an exploratory laparotomy after sustaining a gunshot wound to the abdomen. Which assessment finding is most important for the nurse to report to the health care provider?

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11ecbb05_cafb_2602_b433_0dd32aafa056_MD0009_00 Hypovolemic (hemorrhagic) shock may occur after abdominal trauma or surgery as mesenteric edema resolves and previously compressed sites of bleeding reopen. The shock continuum is staged in severity from initial (I) to irreversible (IV). During the initial stage, there is inadequate oxygen to supply the demand at the cellular level and anaerobic metabolism develops. At this point, there may be no recognizable signs or symptoms. As shock progresses to the compensatory stage, sympathetic compensatory mechanisms are activated to maintain homeostasis (eg, oxygenation, cardiac output). Cold, clammy skin indicates failing compensatory mechanisms (ie, progressive stage), and immediate intervention is necessary to prevent irreversible shock and death (Option A). (Option B) Slightly low oxygen saturation may occur when there is inadequate oxygen supply and increased metabolic demand. It is not the most important finding to report. (Option C) Sinus tachycardia is part of the compensatory response to maintain cardiac output and oxygen demand. It is not the most important finding to report. (Option D) As shock continues, the kidneys decrease filtration and increase reabsorption to maintain blood pressure, eventually resulting in decreased urinary output. Normal urine output is 0.5-1 mL/kg/hr or >30 mL/hr. Educational objective: Cold, clammy skin in a client with shock indicates that compensatory mechanisms are failing and that hypoperfusion is occurring. This should be reported promptly to the health care provider as immediate intervention is necessary to prevent irreversible shock.

The Nurse Is Caring for a Client in the Immediate