Four hours after a rectal resection for treatment of rectal cancer, the patient is noted to be pale and diaphoretic. Which assessments are the priority? Select all that apply.

Pain level , Heart rate , Blood pressure. Following a rectal resection surgery the patient is at risk for untreated pain as well as hemorrhage and shock. Therefore, the priority assessments are pain level, as increased pain can cause pallor and diaphoresis, as well as heart rate and blood pressure, because hypotension and tachycardia can indicate hypovolemic shock due to hemorrhage. Urine output is expected to be decreased or absent up to 8 hours after surgery, so decreased urine output is not a reliable indicator of hypovolemic shock. The respiratory rate is likely increased in both metabolic acidosis caused by hypovolemic shock as well as in severe pain. The patient’s last bowel movement is irrelevant following a rectal resection surgery because the patient would have undergone extensive bowel preparation prior to surgery. Further, an ileus can occur due to anesthesia, pain medication, and surgical manipulation of the bowel.

Four hours after a rectal resection for treatment of rectal cance...

Category: Reduction of Risk Potential
Difficulty: 10

Topics: Assessment Cardiovascular Gastrointestinal Hematology/Oncology Neurology Communication & Documentation Elimination Immunity Inflammation

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