An 82-year-old female patient arrives at the emergency department after a fall off of ladder while putting up her Christmas lights on the outside of her house. She states "I just misstepped on the ladder rung I won't dizzy or anything like that. She currently reports being very dizzy and reports some abdominal pain Vital signs include Heart rate: 115 bpm Blood pressure: 88/54 mm Respiratory rate: 22 breaths per minute Oxygen saturation 56% on room air Skin Cool and clammy What should the nurse watch for in this patient, and what is the first action? (Select all that apply
Explanation & Rationale
A. Monitor for signs of compensatory shock progressing to decompensated shock: The patient’s hypotension, tachycardia, cool clammy skin, and low oxygen saturation indicate hypovolemic or hemorrhagic shock. Close monitoring is essential to detect rapid deterioration and guide interventions. B. Administer pain medication for abdominal pain: While pain management is important, administering analgesics before stabilizing circulation and assessing for internal bleeding may mask critical symptoms and delay life-saving interventions. C. Assess for signs of internal or external blood loss: The fall and current hypotension suggest possible hemorrhage. Assessing for bleeding is a priority to identify the source and guide urgent fluid resuscitation or surgical intervention. D. Establish IV access with a large-bore catheter and prepare to administer fluids: Rapid fluid resuscitation through large-bore IV access is essential to restore circulating volume and support perfusion in a patient showing shock signs. This is a primary life-saving intervention. E. Position the patient in Trendelenburg position to improve blood flow to the brain: Trendelenburg positioning is no longer recommended for shock management as it may impair respiratory function and does not reliably improve cerebral perfusion. F. Monitor for signs of dehydration: The patient’s acute presentation suggests hemorrhagic or hypovolemic shock rather than chronic dehydration. While fluid status is important, acute blood loss is the immediate concern.