During a morning assessment, a nurse notes that a patient has cool, clammy skin, a weak pulse, and decreased urine output. What is the most appropriate nursing action based on these findings?
Report possible hypovolemic shock to the physician
Cool, clammy skin, a weak (thready) pulse and reduced urine output indicate poor tissue perfusion caused by low circulating volume — signs of hypovolemic shock.
Shock is a medical emergency, so the most appropriate action is to report it immediately to the physician so that IV fluid resuscitation and further management can start.
Rapid oral fluids are inadequate and risky, warming blankets do not correct volume loss, and High Fowler’s position can worsen hypotension (the legs should be elevated instead).
Hence, Report possible hypovolemic shock to the physician.
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Important Questions from Medical-Surgical Nursing
Which nursing intervention is most appropriate when caring for a patient experiencing an anaphylactic reaction?
A patient has just returned to the ward after abdominal surgery. Which action should the nurse take first to evaluate the effectiveness of respiratory interventions in the immediate postoperative period?
A nurse is monitoring a patient with a colostomy. Which observation requires immediate attention?
Which solution is commonly used for fluid replacement in burn patients?
In a patient with a normal temperature and pulse but low blood pressure, which clinical condition should be considered first?
