While working in an endoscopy recovery unit, a practical nurse evaluates a client who underwent a colonoscopy with a polypectomy two hours prior. The client complains of a sudden onset of severe, sharp abdominal pain. During the assessment, the nurse palpates a firm, board-like abdomen and observes that the client's heart rate has increased from a pre-procedure baseline of 74 beats per minute to 118 beats per minute. Which action should the nurse take first?
- ADocument the assessment findings as an expected outcome of procedural air insufflation
- BAdminister a prescribed oral analgesic to address the client's severe discomfort
- Notify the registered nurse immediately about the abdominal changes and tachycardiaAnswer
- DAdminister a prescribed intravenous push medication for rapid pain relief
Answer
Notify the registered nurse immediately about the abdominal changes and tachycardia
A firm, board-like abdomen accompanied by sudden severe pain and an increasing heart rate are classic indicators of a bowel perforation, a life-threatening complication of a colonoscopy. The priority action for the practical nurse is to escalate these critical findings immediately to the registered nurse or healthcare provider so that emergency surgical or medical interventions can be initiated.
Step-by-Step Solution
Key Concept
Recognizing and escalating signs of bowel perforation following an endoscopic procedure