Exhibits

Review H and P and nurse's notes.

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. 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. The client opens her eyes to verbal stimuli and follows verbal commands.

Rationale for Correct Choices:

• Heart rate 128 beats/minute, sinus tachycardia: The elevated heart rate of 128 beats/minute suggests tachycardia, which could indicate hypovolemia or shock, especially given the traumatic nature of the injury. This warrants immediate attention to prevent cardiovascular compromise.
• Temperature 96.9° F (36.1° C): A low temperature is concerning in trauma patients and could indicate hypothermia, which worsens in a critical setting. It should be monitored closely and actively managed, especially in the ICU setting.
• Blood pressure 90/79 mm Hg, pulse pressure less than 40 mm Hg: A pulse pressure of less than 40 mm Hg can be a sign of insufficient perfusion and is concerning in trauma. The low blood pressure in combination with the narrowed pulse pressure suggests the possibility of hemorrhagic shock, which requires immediate intervention to stabilize blood volume.
• Ecchymosis noted on the abdomen around the dressing: Ecchymosis around the abdominal dressing, combined with the history of trauma and CT findings of liver and spleen lacerations with peritoneal blood, strongly indicates ongoing internal bleeding.
• Capillary refill is 6 seconds: Delayed capillary refill is a sign of poor peripheral perfusion, which can be indicative of hypovolemic shock or other circulatory compromise. This finding should be addressed promptly to assess circulatory status and address underlying causes.
• No urine noted in the indwelling urinary catheter: The absence of urine output is a critical finding, especially in a trauma patient. It may indicate renal hypoperfusion due to low blood pressure, which can lead to acute kidney injury.

Rationale for Incorrect Choices:

• Respiratory rate 14 breaths/minute: A respiratory rate of 14 breaths/minute is within the normal range for an adult. There are no signs of respiratory distress, so it does not require urgent attention at this time.
• Oxygen saturation 100% on 40% fraction of inspired oxygen (FiO2): The oxygen saturation is 100%, which is within the normal range. The use of 40% FiO2 is appropriate for intubated patients, and no immediate intervention is needed for oxygenation at this time.
• Surgical dressing is clean and dry: The surgical dressing being clean and dry suggests there is no active bleeding at the moment, it does not require urgent intervention unless there are signs of worsening or internal bleeding.
• Lung sounds are clear and equal bilaterally: Clear lung sounds indicate that there are no immediate respiratory issues such as fluid buildup or obstruction. This is a positive finding and does not require urgent attention at this time.