A nurse on a medical surgical unit is admitting a client from a provider's office.

Exhibits

Click to highlight the information in the Nurse's Notes and Vital Signs that should be reported to the provider.

1500:                         

• Temperature: 39 degrees Celcius (102.2 F)
• Heart rate: 122/min
• Respiratory rate: 24/min
• BP: 106/54 mmHg
• Oxygen saturation: 95% on room air

1530:

• Client lethargic, reporting abdominal cramping, experiencing projectile vomiting.
• Voiding dark, concentrated urine.
• Client requesting water

Rationale:
A. Pain assessment is important but not the immediate priority following an EGD. Discomfort is expected after the procedure, yet it does not pose the greatest risk to airway safety.

B. Nausea should be monitored, especially since sedation and irritation of the upper GI tract can cause vomiting, but this is not the most critical concern immediately after the procedure.

C. The gag reflex must be assessed first because topical anesthetics used during the EGD suppress the swallowing and protective airway reflexes. If oral fluids or food are given before the gag reflex returns, the client is at high risk for aspiration, which can lead to pneumonia or airway obstruction. Ensuring the gag reflex has returned is the priority safety measure before advancing the diet or giving oral medications.

D. Level of consciousness should also be assessed, since sedatives are commonly used during the procedure. However, the risk of aspiration from an absent gag reflex presents a more immediate threat to life and therefore takes priority.

Rationale:

• Improved breathing indicates that the removal of ascitic fluid has relieved diaphragmatic pressure, allowing better lung expansion.
• Decreased abdominal pressure demonstrates that fluid removal has reduced intra-abdominal tension, improving mobility and comfort.
• Relief of abdominal discomfort is a primary goal of paracentesis, as it enhances quality of life and reduces pain caused by fluid accumulation.
• Stable vital signs and absence of respiratory distress are important for monitoring safety but are not direct measures of the procedure’s effectiveness.
• Reduced ascitic fluid volume is the mechanism of action of paracentesis, while the client’s symptomatic relief is the best indicator of clinical success.