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Zorluk: Çok zorPhysiological Adaptation

An unlicensed assistive personnel (UAP) reports that a 76-year-old client who underwent a percutaneous liver biopsy three hours ago is now highly restless and disoriented. The client also complains of a new, dull ache in the right shoulder. Baseline vital signs were blood pressure 138/82 mm Hg and pulse 76 bpm. Current vital signs are blood pressure 108/74 mm Hg, pulse 112 bpm, and respirations 22/min. Which action should the practical nurse implement first?

  1. Position the client flat on the right side and immediately notify the registered nurse.Cevap
  2. B
    Provide the prescribed PRN oral analgesic for the reported shoulder discomfort.
  3. C
    Implement fall precautions and frequently reorient the client to the environment.
  4. D
    Document the vital signs and continue to monitor the client every hour.

Cevap

The priority action is to position the client flat on the right side and immediately notify the registered nurse.
The client is demonstrating classic, critical signs of internal hemorrhage and hypovolemic shock. Restlessness and confusion are early manifestations of cerebral hypoperfusion. The new right shoulder ache (Kehr's sign) indicates diaphragmatic irritation from accumulating intra-abdominal blood. Furthermore, the vital signs reveal a significantly narrowed pulse pressure (from 56 mm Hg to 34 mm Hg) and tachycardia, which represent the body's compensatory mechanisms for acute volume loss. Positioning the client flat on the right side uses the rib cage to apply external pressure to the liver capsule, helping to tamponade the bleeding site. Because the client is actively deteriorating, the registered nurse must be notified immediately to initiate medical resuscitation.

Adım Adım Çözüm

1
Analyze the clinical cues presented by the client.
The client exhibits restlessness, disorientation, right shoulder pain, tachycardia (112 bpm), and a narrowing pulse pressure (from 56 mm Hg baseline down to 34 mm Hg).
Identifying these grouped cues is essential to recognize the systemic signs of internal bleeding and hypoperfusion.
2
Correlate the clinical cues with the recent procedure.
The client had a highly vascular liver biopsy. The right shoulder pain is recognized as Kehr's sign, which is referred pain from blood irritating the phrenic nerve and diaphragm.
Understanding the anatomical risks of a liver biopsy connects the localized referred pain and systemic shock signs to active hemorrhage.
3
Determine the priority intervention within the practical nursing scope of practice.
The nurse must apply direct pressure to the internal biopsy site by positioning the client flat on the right side and escalate the critical findings to the RN.
Airway, Breathing, and Circulation (ABC) prioritization dictates that active hemorrhage and impending shock must be addressed immediately with mechanical tamponade and emergency escalation.

Anahtar Kavram

Recognizing and managing internal hemorrhage and hypovolemic shock following a liver biopsy
Tahmini Süre:1m 30s
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Physiological Adaptation

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