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Soru

Zorluk: OrtaPhysiological Adaptation

An adult client is recovering on the medical-surgical unit following a percutaneous liver biopsy. During the afternoon assessment, the client reports a new onset of right shoulder pain. The electronic health record displays a gradual heart rate increase from 72 to 112 beats/min and a blood pressure shift from 124/76 mm Hg to 108/84 mm Hg over the last two hours. What is the priority nursing intervention?

  1. Notify the rapid response team and prepare to administer isotonic intravenous fluids.Cevap
  2. B
    Administer the prescribed as-needed analgesic to alleviate the newly reported shoulder discomfort.
  3. C
    Assist the client into a left lateral position to minimize pressure on the procedural site.
  4. D
    Document the assessment findings and increase the frequency of vital sign monitoring to every 15 minutes.

Cevap

Notify the rapid response team and prepare to administer isotonic intravenous fluids.
The client's presentation—tachycardia, a narrowing pulse pressure (from 48 to 24 mm Hg), and referred right shoulder pain (Kehr's sign)—strongly indicates active internal bleeding from the liver biopsy site. In early hemorrhagic shock, the sympathetic nervous system triggers vasoconstriction, which raises diastolic blood pressure and narrows the pulse pressure, while simultaneously increasing the heart rate. The priority is to recognize these subtle but critical changes and immediately escalate care to the rapid response team while preparing for fluid resuscitation to maintain organ perfusion.

Adım Adım Çözüm

1
Analyze the client's vital sign trends over the last two hours.
The heart rate increased (72 to 112 beats/min) and the pulse pressure narrowed significantly (from 48 to 24 mm Hg).
Identifying subtle shifts in vital signs helps recognize early compensatory mechanisms for volume loss.
2
Interpret the new onset of right shoulder pain in the context of the recent procedure.
Right shoulder pain post-liver biopsy is a classic presentation of Kehr's sign, caused by diaphragmatic irritation from accumulating blood.
Connecting localized symptoms to the anatomical site of the procedure confirms the suspicion of internal hemorrhage.
3
Determine the priority nursing intervention based on the clinical picture.
The client is in early hemorrhagic shock. Immediate medical escalation and volume resuscitation are the highest priorities.
In acute decompensation, preserving circulation and tissue perfusion takes precedence over routine symptom management or further monitoring.

Anahtar Kavram

Early Recognition of Hemorrhagic Shock Post-Procedure
Tahmini Süre:1m 15s
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Physiological Adaptation

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