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Difficulty: HardReduction of Risk Potential

A client who underwent a percutaneous liver biopsy one hour ago is currently resting in a right side-lying position. The client now reports a new onset of dull right shoulder pain. Upon assessment, the practical nurse notes a heart rate of 108 beats/min108\text{ beats/min} and a blood pressure of 106/62 mm Hg106/62\text{ mm Hg}. The client's baseline vital signs prior to the procedure were a heart rate of 74 beats/min74\text{ beats/min} and a blood pressure of 132/82 mm Hg132/82\text{ mm Hg}. Which action is the priority for the practical nurse to take next?

  1. A
    Administer the prescribed as-needed oral analgesic to treat the client's shoulder pain.
  2. B
    Document the assessment findings and repeat the vital signs in 30 minutes.
  3. C
    Assist the client into a supine position to relieve the pressure on the right side.
  4. Immediately report the assessment findings to the supervising registered nurse.Answer

Answer

The priority action is to immediately report the assessment findings to the supervising registered nurse, as the client is exhibiting classic signs of internal hemorrhage.
The client is demonstrating early signs of hemorrhagic shock (resting tachycardia and a significant drop in blood pressure) along with referred pain to the right shoulder, which occurs when blood accumulates under the diaphragm and irritates the phrenic nerve. Because bleeding is a major, life-threatening risk following a highly vascular procedure like a liver biopsy, the practical nurse must recognize these combined signs and immediately escalate the situation to the registered nurse for emergency intervention.

Step-by-Step Solution

1
Analyze the client's post-procedure symptoms.
The client has a new onset of dull right shoulder pain.
Right shoulder pain after a liver biopsy is a classic sign of referred pain caused by blood irritating the phrenic nerve under the diaphragm.
2
Compare the current vital signs to the client's pre-procedure baseline.
The heart rate has increased from 7474 to 108 beats/min108\text{ beats/min} (tachycardia), and the blood pressure has decreased from 132/82132/82 to 106/62 mm Hg106/62\text{ mm Hg} (relative hypotension).
Trending vital signs is essential to identify early physiological deterioration.
3
Synthesize the clinical findings to determine the risk potential.
The combination of referred shoulder pain, tachycardia, and dropping blood pressure strongly indicates internal hemorrhage at the biopsy site.
The liver is a highly vascular organ, making hemorrhage the most significant immediate risk following a percutaneous biopsy.
4
Determine the most appropriate action within the practical nurse's scope of practice.
The nurse must prioritize circulation (ABCs) and immediately escalate the unstable findings to the registered nurse.
Unstable clients with signs of active bleeding require immediate RN and provider intervention; delaying escalation to administer pain medication or continuing routine monitoring could result in severe client harm.

Key Concept

Recognizing and Escalating Signs of Hemorrhage Post-Biopsy
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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