# A 35-year-old patient is brought to the emergency department following a motor vehicle accident with significant blood loss. The patient's blood pressure is 80/50 mmHg, heart rate is 120 bpm, and urine output has decreased to 15 mL/hr. Which nursing intervention should be the priority?

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## 문제

A 35-year-old patient is brought to the emergency department following a motor vehicle accident with significant blood loss. The patient's blood pressure is 80/50 mmHg, heart rate is 120 bpm, and urine output has decreased to 15 mL/hr. Which nursing intervention should be the priority?

A 35-year-old patient was brought to the emergency department following a motor vehicle accident with significant blood loss. Current vital signs show hypotension and tachycardia with signs of poor tissue perfusion.

## 보기

1. Administer oxygen at 2 L/min via nasal cannula
2. Insert a urinary catheter to monitor output
3. Elevate the patient's legs 30 degrees
4. Establish large-bore IV access for fluid resuscitation **✔ 정답**

**정답: 4**

## 해설

In hypovolemic shock, the priority is immediate fluid resuscitation through large-bore IV access to restore circulating blood volume and improve tissue perfusion.

Hypovolemic shock is a life-threatening condition where severe fluid or blood loss leads to inadequate tissue perfusion. Pathophysiologically, reduced circulating blood volume leads to decreased venous return, reduced cardiac output, and compensatory mechanisms such as tachycardia and vasoconstriction.

In this scenario, the patient shows classic signs of hypovolemic shock: hypotension (80/50 mmHg), tachycardia (120 bpm), and oliguria (15 mL/hr) indicating decreased renal perfusion. The priority nursing intervention is establishing large-bore IV access for rapid fluid resuscitation.

Large-bore IV catheters (14-16 gauge) allow rapid administration of crystalloids, blood products, or colloids to restore intravascular volume. The goal is to improve preload, increase cardiac output, and restore adequate tissue perfusion. Fluid resuscitation should be started immediately while preparing other interventions.

Nursing implications include continuous monitoring of vital signs, urine output, mental status, and signs of fluid overload. Early recognition and prompt treatment of hypovolemic shock are crucial to prevent progression to irreversible shock and multiple organ failure. This intervention directly addresses the underlying pathophysiology and has the greatest potential to improve patient outcomes.

## 심화 해설

Clinical Scenario Analysis

This patient presents with classic signs of hemorrhagic (hypovolemic) shock following a traumatic event. The vital signs—blood pressure 80/50 mmHg (hypotension) and heart rate 120 bpm (tachycardia)—indicate a compensatory response to significant intravascular volume loss. The decreased urine output of 15 mL/hr (oliguria) is a critical sign of poor end-organ tissue perfusion, confirming that the body is shunting blood away from the kidneys to preserve flow to the heart and brain. In traumatic cardiac arrest and peri-arrest states, the immediate focus must be on addressing the underlying cause of the shock, which is hypovolemia .

The HOTT protocol (Hypovolaemia, Oxygenation, Tension pneumothorax, Tamponade) identifies hypovolaemia as a primary reversible cause requiring immediate treatment . In the hierarchy of trauma care, restoring circulating volume takes precedence to prevent progression to decompensated shock and cardiac arrest. The best available evidence for emergency nursing care emphasizes that early recognition and prompt fluid resuscitation are the cornerstones of management, with the nurse playing a central role in initiating these time-sensitive interventions . Evidence-based protocols for acute hemorrhage stress that stabilizing hemodynamics through immediate, effective fluid resuscitation is the critical first step to prevent complications and improve outcomes .

Priority Intervention Rationale

**Establishing large-bore IV access for fluid resuscitation (Option 4) is the correct priority.**

The Guidelines for Essential Trauma Care emphasize that initial resuscitation requires the immediate establishment of intravenous access to replace lost intravascular volume . Without venous access, no fluids or blood products can be administered, making this the foundational intervention upon which all other resuscitative efforts depend. A large-bore catheter (e.g., 14- or 16-gauge) is essential because it allows for the rapid infusion of warmed crystalloids or blood products, which is necessary to counteract the profound hypovolemia indicated by the patient's hypotension and reflex tachycardia.

While the other options represent valid nursing actions, they are secondary to volume restoration in the sequence of trauma resuscitation:

- **Administering oxygen (Option 1)** addresses hypoxia, which is a component of the HOTT protocol . However, oxygen delivery to tissues is critically dependent on circulating hemoglobin and blood volume. Supplemental oxygen will be ineffective if the vascular space is empty, as there is insufficient blood to carry the oxygen to the tissues.

- **Inserting a urinary catheter (Option 2)** is essential for accurate monitoring of urine output as a marker of renal perfusion and resuscitation adequacy. However, it is a monitoring tool, not a resuscitative intervention. The priority is to treat the cause of the oliguria (hypovolemia) rather than to simply measure it.

- **Elevating the legs 30 degrees (Option 3)** is a passive leg raise maneuver that can transiently increase venous return by autotransfusing blood from the lower extremities. However, this is a temporary measure that provides a small, non-sustained volume bolus. It is not a substitute for definitive volume replacement through IV access and can delay life-saving fluid administration .

The synthesis of evidence confirms that the nurse's immediate priority is to facilitate the rapid infusion of fluids by securing IV access, as this directly targets the pathophysiological mechanism of hypovolemic shock and is the intervention most likely to reverse the patient's hemodynamic instability .

## 임상 시나리오

Hemorrhagic Shock: Initial Nursing PriorityRapid identification and immediate intervention for hypovolemia
In a trauma patient with signs of hemorrhagic shock (hypotension, tachycardia, oliguria), the immediate priority is to establish large-bore IV access and begin fluid resuscitation. This directly addresses the underlying cause of hypoperfusion by restoring circulating volume.

The goal is to prevent progression from compensated to decompensated shock. A 14- to 18-gauge catheter in the antecubital fossa allows for the rapid infusion of warmed isotonic crystalloids (e.g., Lactated Ringer's) or blood products as ordered.

CautionDo not delay volume replacement for other interventions like oxygen administration or catheter insertion. While important, they are secondary to restoring hemodynamic stability. Continuously reassess lung sounds during rapid fluid administration to monitor for pulmonary edema.

## 핵심 개념

- **Hemorrhagic Shock** — A condition of inadequate tissue perfusion resulting from significant intravascular volume loss due to bleeding.
- **Oliguria** — Decreased urine output, typically defined as less than 30 mL/hr in adults, indicating poor renal perfusion and end-organ damage.
- **Fluid Resuscitation** — The rapid administration of intravenous fluids, often through large-bore access, to restore circulating blood volume and improve hemodynamics.
- **Large-bore IV** — A short, wide-diameter intravenous catheter (e.g., 14-18 gauge) used to deliver fluids and blood products at a high flow rate.
- **Tissue Perfusion** — The passage of blood through the body's tissues, delivering oxygen and nutrients while removing waste products.

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