An 82-year-old client is 8 hours post-operative following the surgical repair of a fractured femur. During the evening rounds, the practical nurse notes the client has become suddenly restless, slightly confused, and is picking at the bedsheets. Current vital signs are a blood pressure of 106/64 mm Hg, a heart rate of 118 beats/min, and a respiratory rate of 24 breaths/min. The client's baseline preoperative vital signs were a blood pressure of 138/76 mm Hg and a heart rate of 82 beats/min. Which action should the practical nurse take first?
- AReorient the client to the environment and document the new onset of confusion as age-related sundowning.
- BAdminister the prescribed as-needed opioid medication, assuming the client's restlessness is caused by uncontrolled surgical pain.
- Obtain the client's oxygen saturation, inspect the surgical dressing for active bleeding, and promptly notify the registered nurse.Cevap
- DRecord the vital signs as acceptable post-operative findings and dim the room lights to encourage sleep.
Cevap
The correct action is to obtain the client's oxygen saturation, inspect the surgical dressing for active bleeding, and promptly notify the registered nurse.
Sudden onset confusion, restlessness, tachycardia, and a downward trend in blood pressure in a post-operative client are hallmark early signs of impaired tissue perfusion. This can be caused by hemorrhage or hypoxia. The practical nurse must prioritize further data collection related to airway, breathing, and circulation (ABC) and immediately report these critical findings to the registered nurse for rapid medical evaluation and intervention.
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Early Recognition of Post-Operative Hypovolemia and Hypoxia
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