A nurse is working in the hospital’s blood bank. He is collecting an autologous blood donation from a patient who will have surgery in a few weeks. Because the patient’s surgery could involve significant blood loss, she has been coming to the hospital’s blood bank every week for the past four weeks. While collecting the blood, the patient complains of feeling faint. The nurse observes that the patient is pale, her skin is cool and clammy, and her breathing appears very rapid and shallow. He immediately clamps the blood collection tubing, covers the patient with a blanket, re-positions the blood donor chair into the Trendelenburg position, and calls for help. Why did the nurse do this?
Explanation
Answer: C - The nurse has correctly recognized the early signs of hypovolemic shock, and reacted appropriately. Hypovolemic shock happens when the body experiences blood loss or significant fluid loss. If the body senses a large blood or fluid loss, it attempts to maintain circulatory homeostasis by increasing pulse and breathing rate and dilating blood vessels, which drops blood pressure. Hypovolemic shock is a medical emergency. Classic signs of shock include pale and clammy skin, rapid and thready pulse, and low blood pressure. Nurses should be aware of these signs and react quickly if they observe them. Untreated shock can result in death. Treatment includes immediately terminating the blood collection, covering the patient, and elevating the patient’s legs above the level of the heart (Trendelenburg position). Watch for signs of respiratory or cardiac arrest, be prepared to initiate CPR if necessary, and call for help.
