A nurse is caring for a client who is admitted to the medical-surgical unit. Client reports, “I’m bloated and my stomach hurts.”.
History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, “It’s a burning sensation that radiates to my back. I think I’ve lost a little weight too.” Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal.
Past medical history: Osteoarthritis.
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco.
Current medications:.
Ibuprofen 800 mg three times daily PRN arthritis pain. Physical Examination:.
General: client appears uncomfortable, diaphoretic.
Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale.
Respiratory: bilateral breath sounds clear.
Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding. Neurological: oriented x 3 (person, place, and time).
Laboratory Results.
0900:.
Hemoccult stool positive (negative).
H. pylori positive (negative).
WBC count 6,700/mm (5,000 to 10,000/mm). Hemoglobin 9.1 g/dL(14to 18g/dL).
Hematocrit 27% (40% to 52%).
Vital Signs.
0900:.
Blood pressure 90/50 mm Hg. Heart rate 118/min.
Respiratory rate 18/min Temperature 37.5° C (99.5° F). Pain rated as 7 on a scale of 0 to 10.
Oxygen saturation 98% on room air.
The nurse reviews the client’s laboratory findings and vital signs.
Select the 5 findings that require immediate follow-up.
A.
Heart rate.
B.
Current medications.
C.
Blood pressure.
D.
Stool results.
E.
Respiratory rate.
F.
WBC count.
G.
Temperature.
H.
Hemoglobin and hematocrit.
The Correct answer and Explanation is:
In this scenario, the five findings that require immediate follow-up are:
A. Heart rate
C. Blood pressure
D. Stool results
H. Hemoglobin and hematocrit
G. Temperature
Explanation
- Heart Rate (A): The client’s heart rate is 118 beats per minute, which indicates tachycardia. This can be a response to pain, hypovolemia, or stress. Given the other findings, it suggests the body is compensating for potential shock or anemia.
- Blood Pressure (C): The client’s blood pressure is significantly low at 90/50 mm Hg, indicating hypotension. This is particularly concerning in the context of abdominal pain and potential internal bleeding, especially with the history of dark, tarry stools, which may indicate gastrointestinal bleeding. Immediate intervention is necessary to stabilize the client.
- Stool Results (D): The positive Hemoccult test indicates the presence of blood in the stool, which is a critical finding. It raises concern for possible gastrointestinal bleeding, which could lead to hypovolemic shock, particularly in conjunction with the low blood pressure and elevated heart rate. This finding necessitates prompt further evaluation.
- Hemoglobin and Hematocrit (H): The hemoglobin level of 9.1 g/dL and hematocrit of 27% are indicative of anemia. This is concerning, particularly given the history of dark stools and signs of potential blood loss. Anemia, especially in the presence of hypotension and tachycardia, requires immediate assessment and intervention.
- Temperature (G): Although the temperature is only mildly elevated at 37.5°C (99.5°F), it can suggest an underlying inflammatory process or infection, particularly in the context of abdominal pain and gastrointestinal concerns. This should be monitored closely, especially if the patient develops additional symptoms.
The combination of these findings indicates that the client may be experiencing a significant gastrointestinal issue, possibly related to peptic ulcer disease or another form of gastrointestinal hemorrhage. Therefore, immediate follow-up is essential to ensure appropriate interventions and stabilize the patient.