A nurse is caring for a client who underwent a percutaneous liver biopsy 4 hours ago. The client is currently positioned on their right side. The client's vital signs are heart rate 116 beats/minute, blood pressure 104/82 mm Hg, respiratory rate 24 breaths/minute, and temperature 98.8°F (37.1°C). The client reports a new onset of right shoulder pain and states, 'I must have slept on my arm wrong.' Which of the following is the most appropriate initial nursing action?
- Assess the client's abdomen for rigidity and notify the healthcare provider.Answer
- BAdminister the prescribed as-needed analgesic for the client's shoulder pain.
- CAssist the client into a supine position to relieve pressure on the right shoulder.
- DDocument the findings and continue to monitor the client's vital signs every hour.
Answer
The most appropriate action is to assess the client's abdomen for rigidity and prepare to notify the healthcare provider, as the assessment findings strongly indicate early hemorrhagic shock.
The client is exhibiting early signs of hemorrhagic shock, indicated by tachycardia (116 beats/minute) and a narrowed pulse pressure (104 systolic minus 82 diastolic equals 22 mm Hg). Furthermore, the new onset of right shoulder pain is a classic presentation of Kehr's sign, which occurs when blood in the peritoneal cavity irritates the phrenic nerve. The nurse must prioritize assessing for further signs of internal bleeding, such as abdominal rigidity, and escalate the findings to the healthcare provider immediately for emergency interventions.
Step-by-Step Solution
Key Concept
Identifying early hemodynamic changes of hemorrhagic shock and recognizing referred pain (Kehr's sign) as a critical indicator of internal bleeding post-procedure.