Exhibits

Highlight the findings that require immediate follow up.

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. Heart sounds are regular. The skin is pink. Capillary refill is 6 seconds. Radial pulses are equal bilaterally. Lung sounds are clear and equal bilaterally. The client has an indwelling urinary catheter in place. No urine noted. The client has no visitors at this time. The social worker is attempting to contact family members.

• Heart rate 128 beats/minute: This is sinus tachycardia and indicates the body is compensating for blood loss or stress. In trauma, especially with known internal bleeding, this is a warning sign of hypovolemia and early shock.
• Blood pressure 90/79 mm Hg: This is hypotension, and in combination with tachycardia, it strongly suggests poor perfusion and possible hemorrhagic shock. It requires immediate fluid resuscitation and evaluation.
• Pulse pressure less than 40 mm Hg: A narrowed pulse pressure reflects low stroke volume, which is common in hypovolemia. It supports the diagnosis of possible ongoing internal bleeding and cardiovascular compromise.
• Capillary refill is 6 seconds: Normal capillary refill is under 2 seconds. A 6-second refill shows significantly delayed peripheral perfusion, a hallmark of systemic hypoperfusion or shock.
• No urine noted: Absence of urine in a catheterized trauma patient suggests reduced renal perfusion, which may be a sign of advancing shock and impending organ dysfunction.
• Temperature 96.9°F (36.1°C): Mild hypothermia in trauma is dangerous. It can worsen coagulopathy and bleeding, contributing to the trauma triad. It should be treated with active warming interventions.
• Ecchymosis noted on the abdomen around the dressing: Bruising in this area, especially with known liver and spleen lacerations, suggests ongoing or worsening internal bleeding. This physical sign must be monitored for expansion or tenderness.