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Zorluk: ZorPhysiological Adaptation

A 74-year-old client is recovering on the orthopedic unit following surgical fixation of a fractured pelvis. The practical nurse (PN) observes that the client, who was previously calm and oriented, is now highly agitated, picking at their intravenous (IV) tubing, and has a resting apical pulse of 116 beats per minute. Which actions should the PN implement immediately? Select all that apply.

  1. Apply a pulse oximeter to evaluate the client's oxygen saturation levelCevap
  2. Inspect the surgical incision site and underlying linens for pooling bloodCevap
  3. Obtain a complete set of vital signs including blood pressure and respiratory rateCevap
  4. D
    Administer the prescribed as-needed (PRN) opioid analgesic to alleviate the agitation
  5. E
    Explain to the family that temporary confusion is an expected side effect of general anesthesia for this age group
  6. F
    Document the elevated heart rate and plan to reassess the client's status during the next scheduled rounds

Cevap

The correct actions are to apply a pulse oximeter, inspect the surgical site for bleeding, and obtain a complete set of vital signs.
Sudden onset of agitation and tachycardia in a postoperative orthopedic client strongly suggests inadequate tissue perfusion. This is most likely secondary to hypovolemic shock (from hemorrhage) or hypoxia (such as from a pulmonary embolism or respiratory depression). The PN must immediately gather objective data regarding the client's ABCs (Airway, Breathing, Circulation) by checking oxygen saturation, obtaining comprehensive vital signs, and assessing for overt signs of bleeding. These findings will dictate the urgent medical interventions needed by the registered nurse and provider.

Adım Adım Çözüm

1
Analyze the clinical cues
The client has sudden onset agitation, confusion, and an elevated heart rate (116 bpm).
In a postoperative orthopedic client, these are classic early signs of physiological decompensation, specifically hypoxia or hypovolemic shock.
2
Prioritize data collection related to Airway, Breathing, and Circulation (ABCs)
The PN must immediately check oxygen saturation and obtain comprehensive vital signs.
These assessments provide immediate, objective data regarding the client's respiratory and hemodynamic stability.
3
Identify specific surgical risks
The PN must inspect the surgical site and underneath the client for pooling blood.
Pelvic fractures have a high risk of massive hidden hemorrhage, which directly causes hypovolemic shock.
4
Eliminate unsafe or delayed interventions
Do not administer opioids, do not dismiss the confusion as normal, and do not delay reassessment.
Giving opioids masks critical symptoms, dismissing confusion ignores a life-threatening change, and delaying care puts the client at risk for severe shock and death.

Anahtar Kavram

Early recognition of hypovolemic shock and hypoxia
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Konular

Physiological Adaptation

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