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Zorluk: Çok zorReduction of Risk Potential

A practical nurse (PN) is caring for a client who is 12 hours postoperative following a transsphenoidal hypophysectomy. The client reports a mild headache and increased thirst. The PN notes that the client has produced 900 mL of pale urine over the past 2 hours. Current vital signs are blood pressure 102/64 mmHg, heart rate 114 beats/min, and respiratory rate 18 breaths/min. Which of the following actions should the PN take FIRST?

  1. A
    Measure the urine specific gravity to confirm a fluid imbalance before escalating the findings.
  2. B
    Instruct the client to drink additional oral fluids to compensate for the large urine volume.
  3. Immediately report the urine output and vital signs to the registered nurse.Cevap
  4. D
    Administer the prescribed as-needed (PRN) oral analgesic and reassess the client's headache in 30 minutes.

Cevap

The correct action is to immediately report the urine output and vital signs to the registered nurse.
The client is exhibiting classic signs of acute Diabetes Insipidus (DI), a common complication following pituitary surgery. The massive loss of dilute urine (900 mL in 2 hours) has led to a fluid volume deficit, evidenced by early signs of hypovolemic shock (heart rate of 114 beats/min and blood pressure of 102/64 mmHg). Immediate escalation to the registered nurse is the priority so that rapid intravenous fluid replacement and synthetic antidiuretic hormone (ADH) can be initiated.

Adım Adım Çözüm

1
Analyze the client's surgical history.
The client had a transsphenoidal hypophysectomy.
This surgery involves the pituitary gland, placing the client at extremely high risk for developing Diabetes Insipidus (DI) due to a sudden decrease in antidiuretic hormone (ADH) production.
2
Evaluate the current clinical findings.
The client has massive polyuria (900 mL in 2 hours), tachycardia (114 beats/min), and a borderline low blood pressure (102/64 mmHg).
These findings collectively indicate acute fluid volume depletion and the early stages of hypovolemic shock.
3
Determine the priority nursing action.
The practical nurse must escalate the findings immediately to the registered nurse.
The client requires urgent medical intervention (intravenous fluid resuscitation and synthetic ADH) to prevent severe cardiovascular collapse. Independent actions will delay life-saving care.

Anahtar Kavram

Recognizing early signs of hypovolemic shock secondary to postoperative Diabetes Insipidus
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Konular

Reduction of Risk Potential

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