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Difficulty: Very hardPhysiological Adaptation

During bedside handoff in a surgical step-down unit, a practical nurse reviews the clinical data of a young adult client who underwent a laparoscopic splenectomy earlier in the day. The client is drowsy but rouses to verbal stimuli. The flow sheet indicates that over the past three hours, the client's heart rate has climbed from 82 to 118 beats per minute, and blood pressure has narrowed from 120/78 to 106/82 mmHg. The client reports new, mild left shoulder pain and slight abdominal fullness. Based on these clinical findings, which action is the priority for the practical nurse to implement?

  1. Notify the supervising registered nurse immediately regarding the vital sign trends and shoulder pain.Answer
  2. B
    Administer the prescribed as-needed analgesic to relieve the anticipated post-laparoscopic shoulder discomfort.
  3. C
    Document the findings as expected postoperative recovery and reassess the vital signs in one hour.
  4. D
    Elevate the head of the bed to a high-Fowler's position to decrease pressure on the diaphragm.

Answer

Notify the supervising registered nurse immediately regarding the vital sign trends and shoulder pain.
The correct action is to immediately notify the registered nurse because the combination of a narrowing pulse pressure, progressive tachycardia, and left shoulder pain (Kehr's sign) strongly suggests acute internal hemorrhage following a highly vascular surgery like a splenectomy. This is a medical emergency requiring rapid intervention beyond independent practical nursing actions.

Step-by-Step Solution

1
Analyze the trend in the client's vital signs over the past three hours.
The heart rate increased significantly to 118 bpm, and the pulse pressure narrowed from 42 mmHg to 24 mmHg.
Recognizing a narrowing pulse pressure combined with tachycardia is critical, as these are early, subtle indicators of compensatory hypovolemic shock.
2
Correlate the physical symptoms with the surgical history and physiological changes.
The client is experiencing new left shoulder pain and abdominal fullness following a splenectomy.
The spleen is a highly vascular organ. Left shoulder pain (Kehr's sign) indicates diaphragmatic irritation from internal abdominal bleeding, rather than routine post-laparoscopic gas pain.
3
Determine the priority nursing intervention based on the practical nursing scope of practice.
The priority action is to escalate these findings to the supervising registered nurse or provider without delay.
The client is exhibiting signs of active internal hemorrhage, a life-threatening medical emergency requiring rapid collaborative intervention and potential surgical revision.

Key Concept

Recognition of early hemorrhagic shock and appropriate clinical escalation
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Physiological Adaptation

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