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Difficulty: MediumReduction of Risk Potential

Four hours after a percutaneous liver biopsy, an assigned client reports the new onset of right shoulder pain. The client's baseline vital signs were a blood pressure of 134/82 mm Hg134/82 \text{ mm Hg} and a heart rate of 76 beats/min76 \text{ beats/min}. The licensed practical nurse (LPN/LVN) assesses current vital signs, noting a blood pressure of 108/72 mm Hg108/72 \text{ mm Hg} and a heart rate of 114 beats/min114 \text{ beats/min}. Which action must the nurse take first?

  1. A
    Document the findings as expected procedural recovery since the systolic pressure is above 100 mm Hg100 \text{ mm Hg}.
  2. Immediately report the assessment findings to the supervising registered nurse.Answer
  3. C
    Administer a prescribed as-needed analgesic and reassess the pain level in thirty minutes.
  4. D
    Reposition the client onto the left side to alleviate pressure on the procedural site.

Answer

Immediately report the assessment findings to the supervising registered nurse.
The client's new right shoulder pain is referred pain from diaphragmatic irritation, which can occur when blood accumulates after a liver biopsy. Combined with tachycardia and a dropping blood pressure, these findings strongly suggest internal bleeding and developing hypovolemic shock. The LPN/LVN must immediately escalate these critical findings to the RN or healthcare provider for rapid intervention.

Step-by-Step Solution

1
Analyze the client's symptoms.
The client has new-onset right shoulder pain after a liver biopsy.
Right shoulder pain is a classic sign of referred pain caused by phrenic nerve irritation, often due to blood accumulating under the diaphragm (subdiaphragmatic hematoma).
2
Compare the current vital signs to the baseline.
The blood pressure has dropped from 134/82 mm Hg134/82 \text{ mm Hg} to 108/72 mm Hg108/72 \text{ mm Hg}, and the heart rate has increased significantly from 76 beats/min76 \text{ beats/min} to 114 beats/min114 \text{ beats/min}.
Identifying trends in vital signs is crucial for detecting early physiological decline.
3
Synthesize the findings to determine the clinical risk.
The combination of referred pain, hypotension, and tachycardia indicates internal hemorrhage and early hypovolemic shock.
The body compensates for blood loss by increasing the heart rate, while the blood pressure begins to fall as volume depletes.
4
Determine the priority nursing action based on the LPN/LVN scope of practice.
The priority is to immediately notify the supervising registered nurse or healthcare provider.
A life-threatening complication requires immediate escalation for advanced assessment, potential fluid resuscitation, and medical intervention beyond the LPN/LVN scope.

Key Concept

Recognizing Post-Procedure Hemorrhage and Hypovolemic Shock
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Topics

Reduction of Risk Potential

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