A 70‑year‑old patient is on Day 3 post‑operative following a partial gastrectomy. The nurse notes the patient looks pale and is clutching their abdomen.

Nursing Assessment Findings: HR 130 bpm, BP 90/50 mmHg, RR 24/min, SpO₂ 95%, Abdomen rigid and tender, NG tube draining coffee‑ground fluid, Urine output 20 mL/hr, patient reports dizziness and nausea

Which nursing action is the highest priority based on the patient’s current condition?

Question

A 70‑year‑old patient is on Day 3 post‑operative following a partial gastrectomy. The nurse notes the patient looks pale and is clutching their abdomen.

Nursing Assessment Findings: HR 130 bpm, BP 90/50 mmHg, RR 24/min, SpO₂ 95%, Abdomen rigid and tender, NG tube draining coffee‑ground fluid, Urine output 20 mL/hr, patient reports dizziness and nausea

Which nursing action is the highest priority based on the patient’s current condition?

BlackTom AI · Accepted Answer

Marked hypotension with tachycardia, oliguria, rigid/tender abdomen and coffee‑ground NG drainage indicates an acute, potentially life‑threatening postoperative deterioration (likely hemorrhage, anastomotic leak or shock). Immediate resuscitation using the ABCDE approach and rapid escalation to the Medical Emergency Team (MET) is therefore the highest priority.

1) Relevant knowledge points and concepts
- ABCDE (Airway, Breathing, Circulation, Disability, Exposure) is the priority framework for assessing and stabilizing unstable patients.  
- Tachycardia (HR 130 bpm) and hypotension (BP 90/50 mmHg) suggest shock; MAP = (2×DBP + SBP)/3 = (2×50 + 90)/3 = 190/3 ≈ 63.3 mmHg (borderline low; <65 mmHg is concerning for inadequate perfusion).  
- Urine output 20 mL/hr is oliguria (<30 mL/hr), indicating poor renal perfusion.  
- Rigid, tender abdomen and coffee‑ground NG drainage after gastrectomy imply intra‑abdominal bleeding, anastomotic leak or peritonitis—all can rapidly deteriorate.  
- MET/rapid response teams provide immediate skilled support for resuscitation and escalation.

2) Step‑by‑step reasoning
- Airway and breathing: ensure airway patency and adequate oxygenation; SpO2 is 95% but work of breathing (RR 24) is elevated—monitor and provide O2 as needed.  
- Circulation: hypotension with tachycardia and low urine output requires immediate IV access, fluid resuscitation, possible blood products, cardiac monitoring and urgent surgical/medical review.  
- Disability/Exposure: assess neurological status and expose abdomen to inspect for signs of bleeding or evisceration while maintaining temperature.  
- Simultaneously call the MET/physician for urgent assessment and transfer to higher acuity care.

3) Calculations shown
- MAP = (2×DBP + SBP)/3 = (2×50 + 90)/3 = 190/3 ≈ 63.3 mmHg.

4) Why the correct answer is correct
Initiating an ABCDE assessment immediately targets life‑threatening problems (airway compromise, hypoxia, circulatory collapse) and organizes urgent interventions. Notifying the MET accelerates access to advanced resuscitation, diagnostics (labs, crossmatch, imaging) and surgical review—essential given the likely hemorrhage/leak.

5) Why other options are incorrect
- Encouraging mobilisation: unsafe in the setting of hypotension, abdominal rigidity and possible intra‑abdominal catastrophe; increases risk of collapse/bleeding.  
- Increasing oral fluids: contraindicated post‑gastrectomy with NG tube and possible GI bleed; patient may be NPO and at risk of aspiration.  
- Administering antiemetic: may relieve nausea but does not address hypotension, oliguria, abdominal rigidity or suspected hemorrhage—not life‑saving.

6) Conclusion
Given the clinical signs of shock and possible intra‑abdominal catastrophe, initiating an ABCDE assessment and notifying the MET is the highest priority. This conclusion matches the provided correct answer: Initiate ABCDE assessment and notify the MET team.

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