A nurse is reviewing the transfer report on a client.

Exhibits

 

A nurse is preparing to receive a client from a residential care facility who is scheduled to arrive on the medical-surgical unit. The nurse has received the following transfer report by telephone from the nurse at the residential care facility.

Click to highlight the statements in the transfer report that require action by the nurse prior to the client's arrival.

70-year old male with reports of mid-abdominal pain for 4 days, rating pain 7 on a 0 to 10 pain scale. Has had decreased appetite for a week. Upper abdomen distention present with decreased bowel sounds in lower abdomen. Client reports nausea and started vomiting orange-brown emesis yesterday afternoon that has foul odor. Last bowel movement 7 days ago. Lungs clear to auscultation. Heart sounds moderate and regular. Vitals: Temperature 37.8° C (100° F), BP 120/80 mm Hg, pulse rate 100/min, respirations 20/min and regular.

 

• Mid-abdominal pain for 4 days, rating pain 7 on a 0 to 10 pain scale: Unrelieved abdominal pain of this severity and duration is clinically significant. The nurse must prepare to assess the pain further, ensure pain management protocols are available, and alert the provider for urgent evaluation upon arrival.
• Upper abdomen distention present with decreased bowel sounds in lower abdomen: This indicates a possible bowel obstruction, a condition that can rapidly become life-threatening. Distention and hypoactive bowel sounds are signs of impaired gastrointestinal motility that warrant immediate assessment and preparation for timely interventions.
• Client reports nausea and started vomiting orange-brown emesis yesterday afternoon that has foul odor: Foul-smelling, brownish emesis suggests fecal vomiting, a classic sign of a lower intestinal obstruction. This is a surgical emergency. The nurse must ensure suction equipment is ready, initiate NPO status, and anticipate imaging and provider notification.
• Last bowel movement 7 days ago: Prolonged absence of bowel movements in conjunction with vomiting and abdominal distention strengthens the concern for complete bowel obstruction. This requires immediate evaluation and cannot be ignored during transfer.

Rationale for Incorrect Choices:

• Lungs clear to auscultation: Clear lung sounds indicate the client is not experiencing acute respiratory distress. Since oxygenation appears intact and there are no signs of pulmonary compromise, this finding does not require urgent intervention before arrival.
• Heart sounds moderate and regular: The presence of regular, moderate heart sounds suggests a stable cardiac rhythm and adequate perfusion. In the absence of arrhythmias, chest pain, or abnormal heart tones, this cardiovascular assessment does not raise urgent concern.
• Vitals: Temperature 37.8° C (100° F), BP 120/80 mm Hg, pulse rate 100/min, respirations 20/min and regular: Although the temperature and heart rate are mildly elevated, they remain within acceptable clinical ranges. These values may reflect a response to discomfort, dehydration, or early infection, but they are not immediately alarming.