Physiological Integrity Q 9
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority?
A. Continuing to monitor the vital signs
B. Contacting the physician
C. Asking the client how he feels
D. Asking the LPN to continue the post-op care
Correct Answer: B. Contacting the physician
The vital signs are abnormal and should be reported immediately. The early detection of changes in vital signs typically correlates with faster detection of changes in the cardiopulmonary status of the patient as well as up-gradation of the level of service if needed. Patient safety is a fundamental concern in any healthcare organization, and early detection of any clinical deterioration is of paramount importance whether the patient is in the emergency department or on the hospital floor.
Option A: Continuing to monitor the vital signs can result in deterioration of the client’s condition. The degree of vital sign abnormalities may also predict the long-term patient health outcomes, return emergency room visits, and frequency of readmission to hospitals, and utilization of healthcare resources.
Option C: Asking the client how he feels will only provide subjective data. Selected parameters are more important during various stages of the recovery period. Initially, respiratory rate and blood pressure are of greater significance during recovery from anesthesia, as it reflects hemodynamic stability and level of anesthetic reversal. Later, after adequate analgesia and pulmonary function has been obtained, pulse rate correlates better with intravascular volume status.
Option D: Assigning an unstable client to an LPN is inappropriate. Much information can be obtained by close monitoring of the vital signs, including blood pressure, pulse, and respiratory rate. More importantly, the trend and changes of these measurements more accurately reflect the patient’s ongoing condition. In the immediate postoperative period, frequent measurements are usually obtained by the recovery room staff.