Assignment task:
Ms. K.Z., a 22-year-old university coed, was rushed to the emergency room 35 minutes after sustaining multiple stab wounds to the chest and abdomen by an unidentified assailant. A witness had telephoned 911. Paramedics arriving at the scene found the victim in severe acute distress. Vital signs were obtained: HR 128 (baseline 80) beats/min, BP 80/55 (baseline 115/80) mmHg, RR 37/min and laboured. Chest auscultation revealed decreased breath sounds in the right lung consistent with basilar atelectasis (i.e., collapsed lung). Pupils were equal, round, and reactive to light and accommodation. Her level of consciousness was reported as "awake, slightly confused, and complaining of severe chest and abdominal pain." Pedal pulses were absent, radial pulses were weak, and carotid pulses were palpable. The patient was immediately started on intravenous Lactated Ringer's solution at a rate of 150 mL/hr.
An electrocardiogram monitor placed at the scene of the attack revealed that the patient had developed sinus tachycardia. She was tachypneic, became short of breath with conversation, and reported that her heart was "pounding in her chest." She appeared to be very anxious and continued to complain of pain. Her skin and nail beds were pale but not cyanotic. Skin turgor was poor. Peripheral pulses were absent with the exception of a thready brachial pulse. Capillary refill time was approximately 7-8 seconds. The patient's skin was cool and clammy.
During transport to the hospital, vital signs were reassessed: HR 138 beats/min, BP 75/50 mmHg, RR 38/min with confusion and IV fluids were doubled. In the ED blood samples were sent for typing and cross-matching and for both chemical and hematologic analysis.
Laboratory test results were:
Patient Case Table 6.1 Laboratory Test Results
Hb 74 g/L
Hct 25%
PaO2 53 mm Hg
PaCO2 52 mm Hg
pH 7.31
SaO2 84% on room air
Questions:
Q1. What type of shock does the nurse anticipate? What clinical manifestations support the anticipated diagnosis? You shall explain the cited clinical manifestation.
Q2. How is the initial infusion of IV solution expected to help her condition?
Q3. Identify, with rationale, any peripheral clinical manifestation of hypoperfusion that were present?
Q4. Explain the relationship between her low Hb and her respiratory status/blood gases.