Review H and P and nurses’ notes. Exhibits Click to highlight which assessment findings should the nurse attend to right away? Admitted client. Vital signs: heart rate 128 beats/minute, rhythm sinus tachycardia, respiratory rate 14 breaths/minute, oxygen saturation 100% on 40% fraction of inspired oxygen, temperature 96.9° F (36.1° C), blood pressure 90/79 mm Hg. Pulse pressure calculated to be less than 40 mm Hg. The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a peripheral intravenous line in the right forearm and one in the left hand. The client also has a right subclavian central venous catheter that is infusing propofol and intravenous fluids.
Explanation & Rationale
Heart Rate: 128 beats/min (Sinus Tachycardia): Sinus tachycardia can be a compensatory response to hypovolemia, internal bleeding, or pain. Given the liver and spleen lacerations identified on the CT scan and blood in the peritoneum, tachycardia may indicate ongoing hemorrhage or hypoperfusion. Blood Pressure: 90/79 mmHg (Narrow Pulse Pressure): A pulse pressure of less than 40 mmHg suggests inadequate perfusion and possible hemorrhagic shock. The systolic blood pressure (90 mmHg) is at the lower limit of normal, but the diastolic pressure (79 mmHg) is elevated, which can indicate compensatory vasoconstriction due to hypovolemia. Immediate fluid resuscitation or blood transfusion may be required to prevent worsening shock. Temperature: 96.9°F (36.1°C): Trauma clients, especially those with hemorrhage, are at risk for trauma triad of death (hypothermia, acidosis, coagulopathy) due to massive fluid shifts and blood loss. Even mild hypothermia can impair coagulation and worsen bleeding, requiring active warming measures (e.g., warm IV fluids, heated blankets). Abdominal Ecchymosis and Hematoma: Significant bruising around the surgical dressing suggests ongoing internal bleeding or vascular injury. Close monitoring is needed to assess for expanding hematoma, increased abdominal distension, or hemodynamic instability.