# A nurse is assessing vital signs for a 68-year-old patient admitted with pneumonia and obtains the following: temperature 101.8°F (38.8°C), pulse 118 bpm, respirations 28/min, blood pressure 88/52 mmHg, oxygen saturation 89% on room air. Which assessment finding requires immediate nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542737 > language: ko > subject: Fundamentals ## 문제 A nurse is assessing vital signs for a 68-year-old patient admitted with pneumonia and obtains the following: temperature 101.8°F (38.8°C), pulse 118 bpm, respirations 28/min, blood pressure 88/52 mmHg, oxygen saturation 89% on room air. Which assessment finding requires immediate nursing intervention? ## 보기 1. Blood pressure 88/52 mmHg with weak peripheral pulses **✔ 정답** 2. Temperature 101.8°F (38.8°C) with diaphoresis 3. Pulse rate 118 bpm with regular rhythm 4. Respirations 28/min with slight use of accessory muscles **정답: 1** ## 해설 Hypotension (BP 88/52 mmHg) with weak pulses indicates cardiovascular compromise and hypoperfusion, requiring immediate intervention in a patient with pneumonia. Other findings (fever, tachycardia, tachypnea) are concerning but less immediately life-threatening. ## 심화 해설 Primary Assessment Finding Requiring Immediate Intervention The patient’s blood pressure of 88/52 mmHg accompanied by weak peripheral pulses is the finding that demands the most urgent nursing action. This combination represents a state of circulatory failure where the macrocirculation is no longer sufficient to sustain adequate blood flow to vital organs. In the context of a serious infection such as pneumonia, this clinical picture is highly suggestive of septic shock, a life-threatening condition where the mismatch between oxygen delivery and tissue consumption becomes critical [1]. While the macrocirculation—reflected by parameters like blood pressure—serves as the conduit for blood flow, hypotension at this level indicates that the body’s compensatory mechanisms are failing. The presence of weak peripheral pulses is a direct clinical sign of tissue hypoperfusion. As blood pressure drops, the body shunts blood away from non-vital areas like the skin and extremities to preserve flow to the heart and brain. This vasoconstriction results in diminished, thready pulses that can be palpated peripherally. It is a crucial bedside indicator that the microcirculation, which is ultimately responsible for delivering oxygen and nutrients to the cells, is likely compromised [1]. The assessment of macrocirculation is essential, but it does not guarantee effective microcirculatory function; a finding of hypotension with poor peripheral perfusion signals that both are failing, making this a true emergency [1]. Analysis of Other Options The other vital sign abnormalities are significant and indicative of a systemic inflammatory response, but they do not represent the same level of immediate, life-threatening decompensation as the hypotensive crisis. - Option 2: Temperature 101.8°F (38.8°C) with diaphoresis. Fever is an expected physiological response to infection and the body's attempt to create an inhospitable environment for pathogens. Diaphoresis is a common accompanying symptom as the body attempts to regulate its elevated temperature through evaporative cooling. While this requires monitoring and antipyretic intervention, it is not an immediate threat to organ perfusion. - Option 3: Pulse rate 118 bpm with regular rhythm. Tachycardia is a classic compensatory mechanism for both fever and hypotension. The heart rate increases to maintain cardiac output in the face of vasodilation from fever and decreased stroke volume from hypovolemia or cardiac depression. A regular rhythm is a reassuring finding that suggests the tachycardia is a sinus response to a physiological stressor, not a primary dysrhythmia. The urgency lies in identifying and treating the underlying cause of the tachycardia, which in this case is the hypotension and shock state addressed in Option 1. - Option 4: Respirations 28/min with slight use of accessory muscles. Tachypnea is an expected finding in pneumonia due to alveolar inflammation, impaired gas exchange, and the resulting hypoxemia indicated by an oxygen saturation of 89%. The slight use of accessory muscles indicates increased work of breathing. While this requires prompt intervention with supplemental oxygen and respiratory support, it is a secondary consequence of the primary infection and hypoxemia. The immediate threat to the patient's life is the progression to shock, which will cause irreversible cellular damage and organ failure if not rapidly corrected [1]. The nurse’s priority is to recognize that the hypotensive, poorly perfused state represents a decompensation from sepsis to septic shock. Early identification of this transition is critical, as it necessitates an immediate escalation of care, including fluid resuscitation, vasopressor support, and broad-spectrum antibiotic administration, to restore tissue perfusion and prevent irreversible organ dysfunction [1].References (research sources) - [1]Beyond blood pressure: a comprehensive overview of clinical indices in shock and tissue hypoperfusion.Research articleKim J, Kim S, Lee JH, Kim S. (2026) · DOI: 10.4266/acc.003425 ## 임상 시나리오 Clinical Guide: Recognizing and Managing Suspected Septic Shock Pathophysiology of Concern In the setting of pneumonia, a profound inflammatory response can lead to massive vasodilation and increased capillary permeability, resulting in a maldistribution of blood flow. This causes a relative hypovolemia and myocardial depression, culminating in persistent hypotension refractory to fluid resuscitation. The macrocirculatory failure (low blood pressure) combined with microcirculatory shunting and dysfunction leads to tissue hypoperfusion, the hallmark of septic shock. Focused Nursing Assessment - **Hemodynamic Monitoring:** Track MAP (Mean Arterial Pressure) trend; a sustained MAP below 65 mmHg is a critical threshold. Assess pulse quality (weak/thready vs. bounding) and capillary refill time (>3 seconds indicates hypoperfusion). - **Perfusion Indicators:** Evaluate mental status changes (confusion, lethargy), urine output (goal >0.5 mL/kg/hr), and skin signs (cool, clammy, mottled extremities). - **Source Identification:** Obtain blood cultures and a serum lactate level immediately. An elevated lactate (>2 mmol/L) is a biomarker for tissue hypoxia and a key component of the Sepsis-3 definition. Immediate Nursing Interventions - **Prioritize Circulation:** Place the patient in a supine position and, if no contraindications exist, elevate the legs to promote venous return. Initiate rapid fluid resuscitation with intravenous crystalloids (e.g., 30 mL/kg bolus) as prescribed, monitoring for signs of fluid overload. - **Ensure Oxygenation:** Apply high-flow oxygen via a non-rebreather mask to target an SpO2 of 94-98%. Prepare for potential advanced airway management if the work of breathing increases or mental status declines. - **Administer Medications:** Anticipate the initiation of broad-spectrum intravenous antibiotics within the first hour of recognition. Prepare to administer vasopressors (e.g., norepinephrine) if hypotension persists despite fluid loading. - **Continuous Reassessment:** Reassess vital signs, peripheral perfusion, and mental status every 5-15 minutes during the initial resuscitation phase to evaluate the response to interventions. Interprofessional Collaboration Immediately notify the Rapid Response Team (RRT) or primary provider with a concise SBAR report: *Situation* (Suspected septic shock), *Background* (Admitted with pneumonia, now hypotensive with weak pulses), *Assessment* (Current vital signs, physical findings of hypoperfusion), *Recommendation* (Request orders for fluid bolus, vasopressors, and transfer to a higher level of care such as the ICU). ## 핵심 개념 - **Septic Shock** — A subset of sepsis with circulatory and cellular/metabolic dysfunction, associated with a higher risk of mortality, often presenting with persistent hypotension requiring vasopressors and elevated lactate. - **Tissue Hypoperfusion** — Inadequate blood flow to the body's tissues, resulting in oxygen and nutrient deprivation, clinically manifested by signs such as weak peripheral pulses, cool extremities, and altered mental status. - **Macrocirculation** — The larger vessels of the circulatory system responsible for transporting blood; parameters like blood pressure and heart rate reflect this system, but do not guarantee functional microcirculation. - **Microcirculation** — The network of small blood vessels including arterioles, capillaries, and venules where the actual exchange of oxygen, nutrients, and waste products occurs at the cellular level. - **Compensatory Mechanisms** — Physiological responses such as tachycardia and peripheral vasoconstriction that the body activates to maintain cardiac output and perfusion to vital organs in the face of a stressor like hypotension or hypoxia. ## 같은 주제 문제 - [A nurse is assessing vital signs for a 45-year-old patient admitted with chest pain. 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