MODULE 1: THE CONCEPT OF ACID–BASE BALANCE Clinical Examples A–C Clinical Example A Jay James is a 24-year-old man who was rock climbing with his friends at a national park 25 miles from the nearest hospital when he suddenly lost his footing and slid 20 feet to the ground. Mr. James was alert and oriented when his friends reached him, and he could move all extremities quite easily. He had multiple scrapes over his anterior chest and a large gash over his left thigh (near the groin), which was bleeding profusely. His friends made a makeshift tourniquet, which slowed the bleeding. They immediately contacted the park ranger, who secured a helicopter to evacuate Mr. James to the nearest hospital. Two large-bore IVs were placed in each arm in-flight, and normal saline was administered. The flight medic placed a 100% nonrebreathing mask on Mr. James. Mr. James became disoriented and confused during the flight. Mr. James arrived in the emergency department (ED) 45 minutes after the fall. On arrival in the ED, Mr. James is lethargic but responsive to painful stimuli. He has multiple abrasions over his chin and neck. His pulse oximetry is 99% on the nonrebreather mask, so the ED team replaces the mask with a nasal cannula at 4 L/m. A repeat pulse oximeter reads 95% saturation. Vital signs are as follows: TO 37.3°C (99.1°F): HR 130 bpm; R 30/min; and BP 100/60 mmHg. Skin is cool and clammy, nail beds are pale, and mucous membranes are dry. All pulses are palpable but weak and thready. Lungs are clear, heart sounds regular. Output via urinary catheter for the past hour is 20 mL. Clinical Reasoning Questions Level I Question 1 The nursing assessment should focus on which system initially? Answer 1 The nursing assessment should initially focus on the cardiovascular system since the most likely cause of the high heart rate and low blood pressure is shock related to loss of blood, which causes compensatory high heart rate and low blood pressure related to volume loss. Question 2 You take note that Mr. James has cool, clammy skin and a thready pulse, what is your priority nursing intervention? Answer 2