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Difficulty: EasyPhysiological Adaptation

Following a percutaneous liver biopsy, a client rests on their right side. As the nurse monitors the client for potential complications, which vital sign change provides the earliest indication of internal hemorrhage?

  1. A
    Blood pressure decreases from 122/80 to 94/60 mm Hg
  2. B
    Respiratory rate decreases from 18 to 12 breaths per minute
  3. Heart rate increases from 74 to 108 beats per minuteAnswer
  4. D
    Oxygen saturation drops to 88% on room air

Answer

An increase in heart rate (tachycardia) is typically the earliest vital sign change indicating internal hemorrhage.
An unexplained increase in heart rate (tachycardia) is typically the earliest physiological sign of bleeding and hypovolemia. The sympathetic nervous system triggers this response to maintain cardiac output and tissue perfusion despite a falling blood volume.

Step-by-Step Solution

1
Identify the primary complication risk associated with a percutaneous liver biopsy.
The liver is highly vascular, making internal hemorrhage a significant post-procedure risk.
Understanding the procedural risks guides targeted assessment.
2
Recall the body's immediate physiological adaptation to acute blood loss.
The sympathetic nervous system activates, causing an immediate increase in heart rate.
This mechanism aims to maintain cardiac output and tissue perfusion despite a drop in circulating blood volume.
3
Differentiate between early and late signs of hemorrhagic shock.
Tachycardia is an early compensatory sign, whereas hypotension and altered oxygenation are later signs that occur when compensation fails.
Prioritizing early recognition allows for timely, life-saving interventions before the client decompensates.

Key Concept

Early recognition of hemorrhagic shock
Estimated Time:45s
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Topics

Physiological Adaptation

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