Hematologic Disorders and Anemia Q 46

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A 35-year-old male was knifed in the street fight, admitted through the ER, and is now in the ICU. An assessment of his condition reveals the following symptoms: respirations shallow and rapid, CVP 15 cm H2O, BP 90 mm Hg systolic, skin cold and pale, urinary output 60-100 mL/hr for the last 2 hours. Analyzing these symptoms, the nurse will base a nursing diagnosis on the conclusion that the client has which of the following conditions?

  

     A. Hypovolemic shock

     B. Cardiac tamponade

     C. Wound dehiscence

     D. Atelectasis

    

    

Correct Answer: B. Cardiac tamponade

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All of the client’s symptoms are found in both cardiac tamponade and hypovolemic shock EXCEPT the increase in urinary output. Cardiac tamponade is a medical or traumatic emergency that happens when enough fluid accumulates in the pericardial sac compressing the heart and leading to a decrease in cardiac output and shock. The diagnosis of cardiac tamponade is a clinical diagnosis that requires prompt recognition and treatment to prevent cardiovascular collapse and cardiac arrest.

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Option A: Patients with hypovolemic shock have severe hypovolemia with decreased peripheral perfusion. If left untreated, these patients can develop ischemic injury of vital organs, leading to multi-system organ failure. The first factor to be considered is whether the hypovolemic shock has resulted from hemorrhage or fluid losses, as this will dictate treatment.

Option C: Dehiscence is a partial or total separation of previously approximated wound edges, due to a failure of proper wound healing. This scenario typically occurs 5 to 8 days following surgery when healing is still in the early stages. The causes of dehiscence are similar to the causes of poor wound healing and include ischemia, infection, increased abdominal pressure, diabetes, malnutrition, smoking, and obesity.

Option D: The word “atelectasis” is Greek in origin; It is a combination of the Greek words atelez (ateles) and ektasiz (ektasis) meaning “imperfect” and “expansion” respectively. It results from the partial or complete, reversible collapse of the small airways leading to an impaired exchange of CO2 and O2 – i.e., intrapulmonary shunt. The incidence of atelectasis in patients undergoing general anesthesia is 90%.

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