Following an exploratory laparotomy, a client is transferred to the surgical unit. Upon admission to the unit, the client's vital signs are blood pressure 132/82 mm Hg, heart rate 82 beats/min, and respiratory rate 16 breaths/min. Two hours later, the client reports feeling 'nervous and unsettled.' The current vital signs are blood pressure 114/92 mm Hg, heart rate 116 beats/min, and respiratory rate 24 breaths/min, with 15 mL of urine output over the past hour. Based on these findings, which of the following actions should the nurse take first?
- Examine the surgical dressing and the area underneath the client for active bleedingCevap
- BAdminister the prescribed as-needed anxiolytic medication
- CElevate the head of the bed to a high-Fowler's position
- DDocument the assessment findings and continue routine monitoring
Cevap
The nurse should examine the surgical dressing and the area underneath the client for active bleeding.
The client is exhibiting hallmark signs of the compensatory stage of shock, likely hypovolemic (hemorrhagic) due to the recent exploratory laparotomy. These early signs include a narrowing pulse pressure (from a baseline of 50 mm Hg down to 22 mm Hg), tachycardia, tachypnea, oliguria, and restlessness or anxiety due to decreased cerebral perfusion. Following the nursing process, the nurse's first action must be to perform a focused assessment to identify the potential source of blood loss (such as a saturated dressing or pooling of blood underneath the client) before notifying the healthcare provider.
Adım Adım Çözüm
Anahtar Kavram
Recognition and initial assessment of early (compensatory) hypovolemic shock in the postoperative period.
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