The nurse is caring for a client who had surgery 1 day ago and is receiving a continuous infusion of fentanyl through an epidural catheter. Which intervention should the nurse perform first?

A. Oxygen saturation 95% on room air A SpO2 of 95% is within acceptable limits, especially in a client who is not exhibiting signs of respiratory distress. This does not require immediate investigation, as it is not low enough to be concerning.

B. Bone misalignment: The client’s collarbone appears out of alignment on the left side. This could indicate a fracture or dislocation that needs to be evaluated further to prevent further injury, ensure proper alignment, and determine the need for stabilization or surgical intervention.

C. Swelling at the site of injury: Swelling at the injury site, especially with a history of trauma, could indicate a fracture or soft tissue damage. The nurse should assess the extent of the swelling to rule out internal bleeding, compartment syndrome, or a fracture requiring urgent management.

D. Nausea and fatigue reported by client: Nausea and fatigue can be symptoms of more serious conditions, such as a concussion or internal bleeding, especially given the trauma to the head. These symptoms should be investigated to rule out any neurological or systemic involvement.

E. Decreased range of motion: The client’s decreased range of motion in the left arm, particularly with the reported intense pain, indicates a potential fracture, dislocation, or significant soft tissue injury. This needs to be further assessed to ensure proper treatment and avoid further complications.

F. Intense pain reported by client: The client reports intense pain (10 on a 0 to 10 scale) in the left arm, along with difficulty moving it. This is a critical symptom, suggesting a possible fracture, dislocation, or soft tissue injury that needs to be addressed immediately.

G. Left arm that is cool to touch: Coolness to the touch in the left arm could indicate a lack of adequate blood circulation, potentially from vascular injury or compression. This requires further evaluation to assess for possible arterial injury or compartment syndrome.

G. Blood pressure of 136/90 mm Hg: While 136/90 mm Hg is elevated for a general population, it is not an immediate life-threatening concern in this acute trauma setting. It could be a normal finding for someone with a history of hypertension, or a temporary elevation due to pain and anxiety from the injury.

Rationale:

• 1+ strength in left upper extremity: Reduced strength in the affected arm could indicate a humeral fracture, which can impair muscle function and strength. A rotator cuff injury could cause pain, but it doesn’t necessarily lead to a reduction in strength to the extent seen with a humeral fracture.
• Decreased range of motion: Decreased range of motion is common with humeral fractures as the bone is likely immobilized and painful to move. A rotator cuff injury can also lead to decreased range of motion due to pain and limited ability to lift or rotate the arm.
• Coolness of skin: Coolness to the skin could indicate poor circulation, which can occur if there is vascular injury related to a humeral fracture or if there is significant swelling causing compression of blood vessels.Coolness is less commonly associated with rotator cuff injuries unless there is concurrent trauma affecting blood flow.
• Reduced pulse distal to injury: Reduced pulses can suggest vascular injury, which is more likely with a humeral fracture, especially if the bone fragments are displacing or compressing blood vessels.This is unlikely with a rotator cuff injury, as it primarily affects the tendons and muscles without significant impact on vascular structures.
• Pain with movement: Pain with movement is a classic symptom of a fracture, particularly when moving the arm or shoulder area. Pain with movement is also a hallmark of a rotator cuff injury, especially when the arm is raised or rotated.