A nurse is evaluating a client who is 4 hours postoperative following an open cholecystectomy. The client's vital signs upon admission to the unit were blood pressure 126/78 mm Hg, heart rate 76 beats/min, and respiratory rate 16 breaths/min. The client's current vital signs are blood pressure 112/86 mm Hg, heart rate 114 beats/min, and respiratory rate 22 breaths/min. The client reports mild abdominal aching. Which of the following is the priority nursing action?
- AAdminister the prescribed intravenous analgesic for the abdominal aching.
- BDocument the vital signs and reassess the client in 30 minutes.
- Assess the surgical dressing and abdomen for signs of bleeding.Answer
- DAssist the client to use the incentive spirometer.
Answer
The priority nursing action is to assess the surgical dressing and abdomen for signs of bleeding.
The client is demonstrating early signs of hypovolemic (hemorrhagic) shock, evidenced by a narrowing pulse pressure (from 48 mm Hg to 26 mm Hg) and new-onset tachycardia. In early shock, the sympathetic nervous system initiates peripheral vasoconstriction to maintain cardiac output, which raises the diastolic blood pressure, while the systolic blood pressure begins to drop or remains initially stable. This results in a narrowed pulse pressure. The priority action is to assess the client's abdomen and surgical dressing for active bleeding to gather critical data before implementing further interventions or notifying the healthcare provider.
Step-by-Step Solution
Key Concept
Early Signs of Hypovolemic Shock and Prioritization
Estimated Time:1m 30s