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The client returns to the nursing unit following an open reduction with internal fixation of the right hip. Nursing assessment findings include:

- Temperature: 100.8 degrees Fahrenheit
- Heart rate: 112 beats per minute
- Respiratory rate: 28 breaths per minute
- Blood pressure: 86/58
- No urine in the Foley catheter collection bag

The nurse interprets these findings as indicating which complication?

Answer :

The symptoms are indicative of shock, possibly from hemorrhage or sepsis, and suggest urgent medical intervention may be necessary.

The findings described in the question suggest the client might be experiencing a complication known as shock, possibly due to hemorrhage or sepsis.

The high temperature and elevated heart rate could indicate an infection or inflammatory process in the body, while the low blood pressure and fast respiratory rate may suggest the body is not maintaining adequate perfusion, which is characteristic of shock.

Furthermore, the absence of urine in the Foley catheter collection bag could be indicative of potential kidney issues or a decrease in circulating blood volume. It is imperative to report these findings to a healthcare provider immediately, as they may require urgent medical intervention.

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Rewritten by : Barada

These results, according to the nurse, point to a hypovolemic shock consequence.

Hypovolemic shock: what is it?

When there has been severe hemorrhage or other water loss, the heart cannot adequately pump blood to the body, leading to an emergency condition called volume depletion shock. This type of assault can cause several organs to stop working. As a consequence of fluid loss, refractory gastroenteritis and minor burns are two diseases that might culminate in hypovolemic shock.

Where does hypovolemic shock occur?

The Postural position (TP) is used to treat hypotension or hypovolemic shock and is described as "a position in which head is low and also the body and feet are on an elevated or raised plane" [2].

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