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Difficulty: HardReduction of Risk Potential

A 54-year-old client is being monitored on the acute care unit 90 minutes after an ultrasound-guided percutaneous liver biopsy. The client's baseline vital signs upon arrival to the unit were a blood pressure of 136/74 mm Hg and a heart rate of 72 beats per minute. Upon reassessment, the nurse notes the client is increasingly restless, with a blood pressure of 114/92 mm Hg, a heart rate of 108 beats per minute, and a respiratory rate of 22 breaths per minute. The client also mentions a newly developed dull ache in the right shoulder. To minimize the risk of a severe physiological complication, which of the following actions must the nurse implement?

  1. Maintain the client in a right lateral position and urgently contact the healthcare provider.Answer
  2. B
    Assist the client into a supine position with the lower extremities elevated to support venous return.
  3. C
    Provide the prescribed as-needed intravenous analgesic to alleviate the reported shoulder discomfort.
  4. D
    Coach the client through deep breathing exercises to manage the elevated respiratory rate and restlessness.

Answer

The nurse must ensure the client remains in a right lateral position and notify the healthcare provider immediately, as the assessment findings indicate internal bleeding and early hemorrhagic shock.
The client is exhibiting early signs of hemorrhagic shock, indicated by the narrowed pulse pressure, tachycardia, and restlessness. Furthermore, new-onset right shoulder pain post-liver biopsy strongly suggests referred pain from diaphragmatic irritation caused by blood accumulation. Maintaining the client in a right lateral position is critical to keep pressure on the liver capsule to tamponade the bleeding site, and the healthcare provider must be notified immediately for further medical intervention.

Step-by-Step Solution

1
Analyze the vital sign trends from baseline to the current assessment.
The blood pressure has dropped and the pulse pressure has significantly narrowed (from 62 mm Hg to 22 mm Hg), accompanied by new tachycardia (108 bpm) and tachypnea (22 breaths/min).
Narrowing pulse pressure, tachycardia, and restlessness are classic compensatory signs of early (stage II) hemorrhagic shock.
2
Evaluate the clinical significance of the client's new right shoulder pain.
The shoulder pain is identified as Kehr's sign.
Following an invasive abdominal procedure like a liver biopsy, right shoulder pain indicates referred pain from blood accumulating under the diaphragm and irritating the phrenic nerve.
3
Determine the priority risk reduction intervention based on the clinical picture.
The nurse must act to control the bleeding and escalate care.
Maintaining a right lateral (side-lying) decubitus position applies direct physical pressure against the chest wall to the liver capsule, which is essential to tamponade the bleeding site until medical intervention occurs.

Key Concept

Early recognition of shock and post-procedure risk mitigation
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Topics

Reduction of Risk Potential

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