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Difficulty: MediumPhysiological Adaptation

An older adult client is receiving care on a medical-surgical unit two days after a partial gastrectomy. The practical nurse (PN) notes that the client has become newly agitated. Current vital signs reveal a heart rate of 118 beats/min, a respiratory rate of 26 breaths/min, and a blood pressure of 92/54 mmHg. The client's vital signs from four hours ago were a heart rate of 82 beats/min, a respiratory rate of 16 breaths/min, and a blood pressure of 128/74 mmHg. Which of the following actions should the PN take? (Select all that apply.)

  1. A
    Administer the prescribed as-needed (PRN) oral sedative to manage the client's agitation.
  2. Notify the registered nurse (RN) immediately regarding the acute changes in the client's condition.Answer
  3. Check the client's surgical incision and abdominal dressings for signs of active bleeding.Answer
  4. D
    Record the vital signs in the chart and wait 30 minutes to recheck them to confirm a trend.
  5. Apply the prescribed supplemental oxygen to support tissue perfusion.Answer
  6. F
    Inform the client's family that mild confusion is a normal response to hospitalization for older adults.

Answer

The correct actions are to notify the registered nurse, check the surgical site for bleeding, and apply prescribed supplemental oxygen.
The correct actions prioritize immediate safety, targeted data collection, and rapid escalation. The client's new-onset agitation, tachycardia, hypotension, and tachypnea strongly suggest hypovolemic shock, possibly from internal or external hemorrhage. Providing oxygen supports breathing, checking the dressing provides crucial data on the potential bleeding source, and notifying the RN ensures the client receives prompt medical intervention.

Step-by-Step Solution

1
Analyze the client's current clinical presentation compared to their baseline.
The client has developed sudden agitation, significant tachycardia, tachypnea, and hypotension.
Identifying changes from baseline helps distinguish between expected postoperative recovery and acute physiological complications.
2
Correlate the symptoms with potential physiological complications.
These findings are classic indicators of early hypovolemic shock, likely due to postoperative hemorrhage.
Agitation is an early sign of hypoxia. The heart rate and respiratory rate increase to compensate for dropping blood pressure and reduced circulating oxygen.
3
Prioritize nursing actions based on the ABCs and the PN scope of practice.
The most critical actions involve supporting oxygenation, gathering essential data regarding the source of bleeding, and immediately escalating the situation to the RN.
Acute decompensation requires immediate collaborative management and life-saving interventions over routine monitoring.

Key Concept

Prioritization of care for clients experiencing acute physiological decompensation and suspected hypovolemic shock.
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Topics

Physiological Adaptation

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