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Zorluk: OrtaReduction of Risk Potential

A client is recovering on the surgical unit 6 hours after an abdominal hysterectomy. The practical nurse reviews the client's vital sign trends over the course of the shift:

TimeBlood PressureHeart RateRespiratory Rate
12:00132/82 mm Hg74 beats/min16 breaths/min
15:00118/74 mm Hg90 beats/min18 breaths/min
18:00100/62 mm Hg114 beats/min22 breaths/min

While the nurse is collecting data at 18:00, the client states, 'I feel really dizzy and my stomach feels unusually tight.' Which action should the practical nurse take first?

  1. A
    Elevate the head of the bed to a high Fowler's position
  2. B
    Administer the prescribed as-needed analgesic for the reported abdominal tightness
  3. C
    Document the findings and plan to reassess vital signs in one hour
  4. Notify the registered nurse or charge nurse immediatelyCevap

Cevap

The correct action is to notify the registered nurse or charge nurse immediately because the client is exhibiting classic signs of internal hemorrhage and developing hypovolemic shock.
The correct action focuses on immediate escalation. The client's vital signs show a clear trend of increasing heart rate and decreasing blood pressure over 6 hours. When combined with symptoms of dizziness and abdominal tightness following a major abdominal procedure, these are classic indicators of internal bleeding and hypovolemic shock. The practical nurse must rapidly report these findings to the registered nurse so collaborative emergency interventions can be initiated.

Adım Adım Çözüm

1
Analyze the vital sign trends from 12:00 to 18:00.
The blood pressure is steadily decreasing (132/82 mm Hg down to 100/62 mm Hg) while the heart rate is significantly increasing (74 to 114 beats/min).
Identifying trends is crucial for recognizing early physiological instability before a critical event occurs.
2
Correlate the vital signs with the client's symptoms and surgical history.
The client had a major abdominal surgery (hysterectomy) and now reports dizziness and a tight abdomen, which aligns with the deteriorating vital signs.
These combined findings strongly suggest intra-abdominal bleeding leading to hypovolemic shock.
3
Determine the appropriate practical nurse (PN) scope of practice.
The PN must immediately escalate these critical findings to the registered nurse (RN) or healthcare provider.
The client requires rapid assessment and intervention (e.g., fluid resuscitation, potential return to surgery) that falls outside the independent scope of the PN.

Anahtar Kavram

Reduction of Risk Potential: Recognizing Postoperative Complications
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Konular

Reduction of Risk Potential

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