# A nurse is caring for a 58-year-old patient hospitalized for suspected gastrointestinal bleeding. During assessment, which finding requires the nurse's highest priority intervention?

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> subject: Adult Health

## 문제

A nurse is caring for a 58-year-old patient hospitalized for suspected gastrointestinal bleeding. During assessment, which finding requires the nurse's highest priority intervention?

## 보기

1. Melena stools reported by the patient
2. Blood pressure 88/52 mmHg with heart rate 118 bpm **✔ 정답**
3. Epigastric pain rated 6/10 on pain scale
4. Hemoglobin level of 9.2 g/dL from morning labs

**정답: 2**

## 해설

Hypotension (88/52 mmHg) with tachycardia (118 bpm) indicates hemodynamic instability from acute blood loss, requiring immediate intervention to prevent shock. Melena, pain, and low hemoglobin are concerning but less urgent.

## 심화 해설

Clinical Priority: Recognizing Hemodynamic Instability

The patient's presentation of blood pressure 88/52 mmHg (hypotension) with a heart rate of 118 bpm (tachycardia) is a classic compensatory mechanism for hypovolemic shock. In the context of suspected gastrointestinal bleeding, this vital sign pattern indicates that the patient has lost a significant volume of circulating blood, and the body is no longer able to maintain adequate perfusion pressure through vasoconstriction and increased heart rate alone. This represents a state of decompensated shock, where oxygen delivery to vital organs is critically impaired [1].

The selection of this finding as the highest priority aligns with the principle of addressing immediate threats to circulation before other concerns. While the traditional trauma resuscitation sequence follows Airway, Breathing, Circulation (ABC), emerging evidence in patients with life-threatening hemorrhage supports a shift to prioritizing circulation, as reflected in the Circulation, Airway, Breathing (CAB) approach. This strategy is grounded in the understanding that post-intubation hypotension can be profoundly deleterious in a patient who is already volume-depleted, and the most immediate, life-saving intervention is to restore circulating volume and control the source of bleeding [2].

The other findings, while clinically significant and directly related to the suspected diagnosis, do not represent the same level of immediate threat. Melena (option 1) is a key indicator of upper gastrointestinal bleeding but is a sign of the underlying pathology, not an immediate hemodynamic crisis. Epigastric pain (option 3) requires assessment and management but is not the priority over circulatory collapse. A hemoglobin level of 9.2 g/dL (option 4) confirms anemia and blood loss; however, a single laboratory value reflects a moment in time and may lag behind the patient's acute hemodynamic status. The nurse's immediate action must be to respond to the direct evidence of poor end-organ perfusion—the hypotension and reflex tachycardia—by initiating rapid fluid resuscitation and promptly notifying the healthcare provider to escalate care, as this state can rapidly progress to irreversible shock and cardiac arrest [1].

References (research sources)

- [1]Best evidence for fluid resuscitation nursing in hypovolemic shock patients in emergency care based on GRADE system.Research articleWang Y, Lin J, Lin Y. (2026) · DOI: 10.2478/abm-2026-0009

- [2]Prioritizing circulation over airway in trauma patients with exsanguinating injuries: What you need to know.Research articleFerrada P, Duchesne J, Piehl M. (2025) · DOI: 10.1097/ta.0000000000004618

## 임상 시나리오

Hemorrhagic Shock RecognitionPrioritizing Circulation in GI Bleeding
A blood pressure of 88/52 mmHg with a heart rate of 118 bpm indicates decompensated hypovolemic shock. The tachycardia is a compensatory response to profound volume loss, signaling that vasoconstriction alone can no longer maintain perfusion pressure.

In life-threatening hemorrhage, shift from the traditional ABC to the CAB (Circulation, Airway, Breathing) approach. The immediate priority is to restore circulating volume with intravenous fluids or blood products and identify the bleeding source.

CautionDo not delay fluid resuscitation for diagnostic procedures. Post-intubation hypotension is a significant risk in volume-depleted patients; prioritize circulatory support before airway manipulation if the patient is breathing spontaneously.

## 핵심 개념

- **Decompensated Shock** — A critical state where the body's compensatory mechanisms (tachycardia, vasoconstriction) fail to maintain adequate blood pressure and organ perfusion.
- **CAB Approach** — A resuscitation priority sequence (Circulation, Airway, Breathing) used in life-threatening hemorrhage to prioritize volume restoration and prevent post-intubation hypotension.

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