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학습 자료 둘러보기 →In a client with acute cholecystitis, the development of low blood pressure (88/52 mmHg), rapid heart rate (118 bpm), and cool, clammy skin signals a transition from localized infection to septic shock. This represents a hemodynamic emergency where systemic vasodilation and capillary leak cause profound hypoperfusion.
Immediate nursing actions focus on the Circulation component of the ABCs. Notify the provider urgently, establish large-bore IV access, and initiate rapid fluid resuscitation with isotonic crystalloids as prescribed. Continuous monitoring of vital signs and urine output is critical to assess response.
Do not delay intervention for other findings like fever or a positive Murphy's sign. While these are important, they do not pose the same immediate threat to life as hemodynamic instability. Early recognition and treatment of shock prevent progression to multi-organ failure.
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