A patient arrives in the emergency department with clinical manifestations consistent with a lower gastrointestinal bleed. What should the nurse assess to determine the patient's stability?
1. Hemoglobin
2. Hematocrit
3. Vital signs
4. Abdominal rigidity to determine the amount of blood being lost
3
Rationale 1: Initially the patient's hemoglobin will not illustrate the true blood loss. This is due to a 6–12 hour delay in intravascular equilibrium related to blood loss.
Rationale 2: Initially the patient's hematocrit will not illustrate the true blood loss. This is due to a 6–12 hour delay in intravascular equilibrium related to blood loss.
Rationale 3: The evaluation of vital signs is the best means to determine the patient's stability. Vital signs provide information concerning cardiac and vascular compensation.
Rationale 4: Abdominal rigidity will provide a key to the presence of blood in the abdomen but it does not distinguish the amount of bleeding or the patient's level of homeostasis nor does it pinpoint the location.
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