QLexNursing

Heart rate 121 beats/minute

🚨 A heart rate over 100 bpm indicates tachycardia, which in this client may signal early sepsis, pain response, or fluid volume deficit.

🚨 Tachycardia is a compensatory response to fever, pain, and intraperitoneal inflammation, such as appendicitis.

🚨 This elevated heart rate aligns with signs of systemic inflammatory response syndrome (SIRS).

🚨 Persistent tachycardia requires monitoring and fluid resuscitation, which is already initiated with Lactated Ringer’s.

🚨 It is a vital sign abnormality that requires prompt attention to guide stabilization efforts.

Respirations 28 breaths/minute with shallow breathing

🚨 A respiratory rate >20 is considered tachypnea, a compensatory mechanism to metabolic acidosis, pain, or anxiety.

🚨 Shallow breathing may also suggest the client is guarding due to severe abdominal pain, impairing adequate ventilation.

🚨 This pattern raises concern for respiratory fatigue, hypoventilation, or hypoxia, even if SpO₂ is temporarily normal.

🚨 Tachypnea may reflect early sepsis, where increased oxygen demand and perfusion abnormalities occur.

🚨 Respiratory rate is one of the most sensitive early indicators of clinical deterioration.

Severe abdominal pain in right lower quadrant

🚨 This is a hallmark symptom of acute appendicitis, especially when sudden in onset and localized to the RLQ.

🚨 It signals possible inflammation or obstruction of the appendix, potentially progressing to perforation if untreated.

🚨 Pain rated 9/10 requires analgesia and monitoring, and it also guides imaging and diagnostic prioritization.

🚨 RLQ pain with rebound or guarding may suggest peritoneal involvement, increasing urgency for surgery.

🚨 Pain is also a major contributor to the client’s tachycardia and respiratory changes.

Temperature 100.8° F (38.2° C)

🚨 This low-grade fever supports a systemic inflammatory response, common in early appendicitis or infection.

🚨 Fever paired with elevated HR and RR meets SIRS criteria, placing the client at risk for sepsis.

🚨 It supports the CT findings of fat stranding and appendix dilation, confirming a localized infectious process.

🚨 Timely intervention, including antibiotics and fluids, is essential to prevent progression to septic shock.

🚨 Monitoring temperature trends is also important to gauge response to treatment.

Vomiting small amounts of green bile

🚨 Bilious emesis indicates upper GI irritation or obstruction, often seen in appendicitis or other abdominal pathologies.

🚨 It may also be a sign of delayed gastric emptying due to inflammation, pain, or ileus.

🚨 Vomiting increases risk for fluid and electrolyte imbalances, requiring IV fluid replacement and antiemetics.

🚨 In combination with RLQ pain and fever, this supports the diagnosis of acute surgical abdomen.

🚨 It may also indicate worsening progression if paired with dehydration or worsening vitals.