A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
A.
Heart rate 180/min
B.
Motled skin
C.
Hypokalemia
D.
Blood pressure 115/68 mm Hg
The Correct Answer and Explanation is:
The correct answer is D. Blood pressure 115/68 mm Hg.
Explanation:
Shock is a critical condition characterized by inadequate tissue perfusion and oxygenation, leading to cellular and organ dysfunction. The compensatory stage of shock is the initial phase in which the body activates various mechanisms to maintain perfusion to vital organs despite the reduced cardiac output or circulating blood volume.
Compensatory Mechanisms: In the compensatory stage of shock, the body attempts to preserve blood flow to essential organs (brain, heart) by initiating compensatory mechanisms such as:
- Increased Heart Rate: The sympathetic nervous system releases catecholamines (like adrenaline), which increase heart rate and contractility to maintain cardiac output.
- Vasoconstriction: Peripheral vasoconstriction occurs to redirect blood flow from non-essential organs to vital organs, helping maintain blood pressure.
Expected Findings in the Compensatory Stage:
- Blood Pressure: In this stage, blood pressure is often within normal limits, as the body is still able to compensate. A blood pressure of 115/68 mm Hg indicates that the compensatory mechanisms are effectively maintaining adequate perfusion.
- Heart Rate: While the heart rate may be elevated, it typically remains within a range that supports cardiac output (usually less than 150 bpm). A heart rate of 180/min would suggest progression to a more severe stage of shock, such as the decompensatory stage.
- Skin Appearance: Mottled skin often occurs in later stages of shock when perfusion to the skin and extremities is severely compromised. It is more commonly associated with the progressive stage of shock.
- Electrolytes: Hypokalemia (low potassium levels) is not a specific indicator of the compensatory stage of shock. Electrolyte imbalances can occur in various conditions, but they are not a hallmark of the compensatory phase of shock.
Conclusion:
In the compensatory stage of shock, the body’s homeostatic mechanisms are still effective at maintaining blood pressure within a normal range, despite the underlying issues. Blood pressure of 115/68 mm Hg is consistent with the body’s ability to compensate, making option D the correct answer. Other findings, such as a significantly elevated heart rate, mottled skin, or hypokalemia, are more indicative of progression to more advanced stages of shock.