A client with blunt trauma undergoes an exploratory laparotomy to repair the intraabdominal injury. After 24 hours, the client has a nasogastric tube attached to continual low suction, 2 Hemovac closed-wound suction abdominal drains, and is receiving IV Ringer's lactate and continual epidural morphine. The client now develops hypotension, tachycardia, oliguria, and severe nausea. What is the client's priority nursing diagnosis (ND) at this time?

Question

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This client is exhibiting symptoms of hypovolemia, which include hypotension, tachycardia, and decreased urinary output. Therefore, the priority ND is deficient fluid volume related to active intravascular loss that is secondary to hemorrhage, gastric suction, wound drainage, and possible third spacing as evidenced by decreased urine output, hypotension, and tachycardia. The adverse effects of the epidural anesthesia can contribute to hypotension as well. This ND poses the greatest threat to survival because if not corrected, it can lead to decreased cardiac output, acute renal failure, and hypovolemic shock. (Option B) Impaired urinary elimination refers to a dysfunction in urinary elimination, such as incontinence, retention, frequency, urgency, dysuria, hesitancy, and nocturia. It is not an appropriate ND for this client. (Option C) Nausea is most likely an adverse effect of the morphine, and an antiemetic will be prescribed. It is an appropriate ND as dry heaving and vomiting can compromise the integrity of the abdominal wound incision. However, it is not the priority ND. (Option D) Clients with trauma are at risk for microbial invasion secondary to inadequate primary defense (eg, skin barrier, catheters), secondary defenses (eg, decreased blood), and environmental exposure (eg, invasive procedures). However, this is not the priority ND. Educational objective: Deficient fluid volume, nausea, and risk for infection are appropriate NDs for a client who has undergone surgery for repair of a blunt trauma intraabdominal hemorrhagic injury. However, the priority ND addresses the highest level of risk to a client: airway, breathing, circulation (eg, hypovolemia, cardiac output), and vital signs (eg, hypotension, tachycardia).

A Client with Blunt Trauma Undergoes an Exploratory Laparotomy to Repair