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Difficulty: HardPhysiological Adaptation

A practical nurse (PN) is collecting data on an 82-year-old client who is 24 hours postoperative following an open cholecystectomy. Which of the following assessment findings should the PN report to the registered nurse (RN) immediately? (Select all that apply.)

  1. The client suddenly does not recognize family members and attempts to pull out the intravenous (IV) line.Answer
  2. Heart rate of 114 beats/min with a blood pressure of 98/64 mm Hg.Answer
  3. Urine output of 45 mL collected in the indwelling catheter bag over the past 2 hours.Answer
  4. D
    The client reports incisional pain as 6 on a 0 to 10 scale when taking a deep breath.
  5. E
    A small amount of dark red drainage is observed on the surgical dressing.
  6. F
    The client expresses mild anxiety regarding how they will manage their wound care at home.

Answer

The correct findings to report immediately are sudden confusion, a heart rate of 114 beats/min with blood pressure of 98/64 mm Hg, and a urine output of 45 mL over 2 hours.
The correct options represent acute, life-threatening changes indicating physiological decompensation. Sudden confusion in an older adult is frequently an early sign of hypoxia or systemic infection. A heart rate of 114 beats/min with a blood pressure of 98/64 mm Hg represents borderline vital signs that are early compensatory mechanisms for hypovolemic shock or internal bleeding. A urine output of 45 mL over 2 hours (averaging less than 30 mL/hr) indicates severely compromised organ perfusion. These findings require immediate RN notification to prevent further clinical deterioration.

Step-by-Step Solution

1
Analyze the clinical context and the client's risk factors.
The client is an 82-year-old adult, 24 hours post-abdominal surgery, placing them at high risk for complications like hemorrhage, fluid volume deficit, and hypoxia.
Establishing the postoperative timeframe and age-related risks helps differentiate expected recovery signs from acute decompensation.
2
Evaluate each assessment finding using the Airway, Breathing, Circulation (ABC) prioritization framework.
Sudden confusion (hypoxia indicator), tachycardia with borderline hypotension (shock indicator), and oliguria (poor perfusion) are all critical ABC threats.
Life-threatening physiological changes must be escalated to the RN immediately to prevent irreversible organ damage.
3
Identify and exclude expected or non-emergent findings.
Incisional pain, a small amount of dark surgical drainage, and discharge anxiety are expected or stable findings for this postoperative stage.
Expected findings require routine nursing care and documentation but do not require emergency escalation over active physiological deterioration.

Key Concept

Recognizing early signs of physiological decompensation and shock in postoperative older adults.
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Topics

Physiological Adaptation

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