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
In a patient with a normal temperature and pulse but low blood pressure, which clinical condition should be considered first?
A nurse is tasked with teaching newly diagnosed hypertensive patients about medication adherence. What approach reflects effective teaching responsibility?
A nurse is evaluating elimination needs of a patient with a newly established colostomy. Which action demonstrates best practice for promoting self-care?
During a complex surgical procedure, the surgical team realizes a critical piece of equipment is malfunctioning. What is the most appropriate action for the nurse in charge of operation theatre supplies?
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