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A patient is admitted to the emergency department (ED) following a motorcycle accident. Upon assessment, the patient's vital signs reveal blood pressure (BP) of 80/60 mm Hg and heart rate (HR) of 145 beats per minute (bpm). The patient's skin is cool and clammy. Which of the following patient medical orders will the nurse complete first?

a) 100% oxygen per nonrebreather mask
b) C-spine x-rays
c) Two large-bore IVs and begin crystalloid fluids
d) Type and cross match

1 Answer

2 votes

Final answer:

The nurse should first initiate two large-bore IVs and begin crystalloid fluids to address the patient's critical condition due to low BP and high HR following an accident. Ensuring adequate volume restoration and tissue perfusion is the top priority.

Step-by-step explanation:

Emergency Care for a Motorcycle Accident Patient

When a patient arrives in the emergency department with vital signs of low blood pressure (BP) at 80/60 mm Hg and an elevated heart rate (HR) of 145 beats per minute, along with signs of cool and clammy skin, the primary concern is to stabilize the patient's condition. In such a critical situation, the first medical order a nurse should prioritize is two large-bore IVs and begin crystalloid fluids. This is crucial to rapidly restore circulating volume, correct hypotension, and improve tissue perfusion.

Following the initial stabilization with IV fluids, 100% oxygen per nonrebreather mask should be administered to ensure appropriate oxygenation. Once the patient's hemodynamic status is stable, other diagnostic procedures such as C-spine x-rays can be considered to assess for any cervical spine injuries. If a blood transfusion seems necessary and there's no time to determine the patient's blood type, O negative blood would be transfused as it is considered the universal donor type, being compatible with any patient in an emergency.

In the scenario where a patient arrives at the emergency department with dangerously low blood pressure, the normal maintenance of blood colloid osmotic pressure means that the net filtration pressure might be decreased. This reduction in net filtration pressure indicates that fluid will be less likely to filter out of the capillaries into the tissue, which helps prevent further fluid loss from the intravascular space, although it doesn't address the underlying cause of hypotension.

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