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Difficulty: MediumPhysiological Adaptation

A nurse is caring for a client who is 4 hours postoperative following a bowel resection. The client's preoperative blood pressure was 132/78 mm Hg and heart rate was 76 beats/min. The nurse now notes a blood pressure of 108/88 mm Hg, a heart rate of 116 beats/min, a respiratory rate of 22 breaths/min, and an oxygen saturation of 97% on room air. The client reports incisional pain as 5 on a 0 to 10 scale. Which of the following is the priority nursing action?

  1. Assess the client's surgical dressing and abdominal drains.Answer
  2. B
    Administer the prescribed PRN intravenous analgesic.
  3. C
    Document the findings and reassess vital signs in one hour.
  4. D
    Assist the client to use the incentive spirometer.

Answer

The priority action is to assess the client's surgical dressing and abdominal drains.
The client is exhibiting early signs of compensatory shock, characterized by tachycardia and a narrowed pulse pressure (108 - 88 = 20 mm Hg). In a postoperative client, this strongly suggests hypovolemia or hemorrhage. The priority is to assess the surgical site and drains for active bleeding to provide critical information to the healthcare provider.

Step-by-Step Solution

1
Analyze the client's vital signs and compare them to the preoperative baseline.
The client has developed significant tachycardia (116 beats/min) and a narrowed pulse pressure (20 mm Hg, down from a baseline of 54 mm Hg).
Identifying trends in vital signs is crucial for detecting clinical deterioration early.
2
Interpret the clinical significance of the vital sign changes.
A narrowing pulse pressure and tachycardia in a postoperative client are classic signs of the compensatory stage of hypovolemic or hemorrhagic shock.
The body attempts to maintain cardiac output and tissue perfusion by increasing the heart rate and causing peripheral vasoconstriction (which raises the diastolic blood pressure).
3
Determine the priority nursing action based on the airway, breathing, circulation (ABC) framework.
Circulatory assessment is the highest priority to identify the source of potential fluid or blood loss.
Before contacting the healthcare provider, the nurse must assess the surgical site for active bleeding to provide complete, actionable information for further medical interventions.

Key Concept

Recognition of early (compensatory) shock signs and prioritization of care
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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