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Zorluk: OrtaPhysiological Adaptation

A 77-year-old client is resting in the surgical unit one day after an open cholecystectomy. Previously conversant and calm, the client abruptly becomes restless, fails to recognize visiting family members, and reports intense abdominal aching. The practical nurse evaluates the client and records a blood pressure of 96/60 mm Hg, a pulse of 108 beats per minute, respirations at 24 breaths per minute, and an oxygen saturation of 93% on room air. Which immediate interventions should the practical nurse prioritize? (Select all that apply.)

  1. Inspect the surgical incision site and surrounding abdomen for firmness, swelling, or active bleeding.Cevap
  2. Urgently report the abrupt cognitive changes and current hemodynamic status to the charge nurse.Cevap
  3. Verify the patency of the client's existing peripheral intravenous catheter.Cevap
  4. D
    Provide the prescribed breakthrough opioid medication to manage the severe abdominal pain.
  5. E
    Reassure the family that sudden confusion is a standard reaction to anesthesia in elderly clients.
  6. F
    Continue with the established vital sign routine because the recorded measurements are nearly within normal limits.

Cevap

The correct interventions are to inspect the surgical site for bleeding, report the changes to the charge nurse, and verify intravenous patency.
The client is exhibiting classic signs of early shock (mild hypotension, tachycardia, tachypnea) and poor cerebral perfusion (sudden agitation and delirium) following abdominal surgery. The practical nurse must prioritize assessing for the source of potential bleeding, ensuring an open intravenous line is ready for rapid fluid resuscitation, and immediately escalating these critical findings to the supervising registered nurse.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The combination of sudden agitation, abdominal pain, mild hypotension (96/60 mm Hg), tachycardia (108 bpm), and tachypnea (24 breaths/min) is identified.
Recognizing early physiological deviations is essential to identify high-risk complications like hypovolemic shock or internal bleeding.
2
Prioritize actions based on the ABCs (Airway, Breathing, Circulation).
Interventions that address potential circulatory collapse and physiological safety are selected over pain management.
In emergent scenarios, stabilizing systemic perfusion and oxygenation supersedes secondary issues like discomfort.
3
Select interventions within the practical nurse scope of practice.
Data collection (inspecting the abdomen), ensuring safety (verifying IV access), and escalating care (reporting to the RN) are chosen.
The practical nurse must gather focused data and prepare the client for rapid medical intervention while collaborating with the healthcare team.

Anahtar Kavram

Recognizing early signs of shock and physiological delirium in the postoperative older adult.
Tahmini Süre:1m 30s
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Konular

Physiological Adaptation

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