An older adult resident at a skilled nursing facility experienced an unwitnessed ground-level fall earlier in the shift. During a follow-up evaluation, the licensed practical nurse observes a blood pressure of (baseline ) and a heart rate of (baseline ). The resident appears pale and reports feeling unusually fatigued. Which action is the priority for the nurse?
- Immediately escalate these clinical findings to the supervising registered nurse.Answer
- BAllow the resident to rest in bed and recheck the blood pressure during the next scheduled round.
- CAdminister a prescribed as-needed mild analgesic to treat the resident's discomfort.
- DConduct a comprehensive initial physical assessment to determine the origin of the blood loss.
Answer
The priority action is to immediately notify the supervising registered nurse about the abnormal vital signs, which strongly suggest internal bleeding.
The correct action is to immediately alert the supervising registered nurse. A significant drop in blood pressure combined with tachycardia following physical trauma (such as a ground-level fall) strongly suggests internal bleeding and developing hypovolemic shock. This requires urgent medical evaluation, continuous monitoring, and intervention to reduce the risk of further decline.
Step-by-Step Solution
Key Concept
Early Recognition of Shock and Escalation of Care