A practical nurse (PN) is reviewing clinical data for a 74-year-old client who is 12 hours post-operative following an open bowel resection with colostomy placement. The client is receiving continuous intravenous (IV) fluids and pain management via patient-controlled analgesia (PCA). Which of the following findings indicate a high risk for a developing complication and require immediate escalation to the registered nurse (RN)? Select all that apply.
- The client's heart rate has increased from a preoperative baseline of 78 beats/min to 116 beats/min, with a current blood pressure of 104/68 mm Hg.Answer
- The client exhibits new-onset restlessness, repeatedly pulling at the bedsheets and asking to get out of bed.Answer
- The client's most recent laboratory results show a hemoglobin level of 9.4 g/dL (94 g/L), down from a preoperative level of 13.8 g/dL (138 g/L).Answer
- DThe client reports a pain level of 6 on a 0-to-10 scale at the surgical incision site when attempting to use the incentive spirometer.
- EThe client's colostomy stoma appears dark pink to beefy red, moist, and slightly edematous.
- FThe client's total urinary output via the indwelling catheter over the past 4 hours is 140 mL of dark yellow urine.
Answer
The findings requiring immediate escalation are the increasing heart rate with borderline blood pressure, the new-onset restlessness, and the significant drop in hemoglobin.
The correct selections all point to a developing postoperative hemorrhage and subsequent hypovolemic shock. A dropping hemoglobin level confirms blood loss, while the compensatory tachycardia and new-onset restlessness (indicating cerebral hypoxia) are classic early signs of shock that demand immediate RN and provider intervention.
Step-by-Step Solution
Key Concept
Early recognition of hypovolemic shock and internal hemorrhage requires synthesizing subtle vital sign changes, neurological alterations, and critical laboratory trends.