A nurse is caring for a client who underwent a splenectomy 12 hours ago. Which assessment finding would be the nurse's priority concern?

Left shoulder pain (Kehr's sign) with restlessness suggests internal bleeding and diaphragmatic irritation, requiring immediate intervention for potential hypovolemic shock. Other findings are less urgent post-operative concerns.

Priority Concern After Splenectomy: Recognizing Intra-abdominal Hemorrhage

The priority assessment finding requiring immediate attention is left shoulder pain and restlessness. In the context of a recent splenectomy, this combination of symptoms is a classic and highly concerning presentation for intra-abdominal hemorrhage with diaphragmatic irritation, often referred to as Kehr's sign. This is a life-threatening postoperative complication that demands rapid recognition and intervention.

The physiological basis for this finding lies in the spleen's anatomic location and its rich vascular supply. The spleen is a highly vascular organ located in the left upper quadrant, directly beneath the diaphragm. Postoperative hemorrhage from the splenic bed or ligated vessels, such as the splenic artery or vein, leads to blood accumulating in the subphrenic space. This collection of blood irritates the phrenic nerve, which innervates the diaphragm. Because the phrenic nerve shares cervical nerve roots (C3-C5) with sensory nerves supplying the shoulder and supraclavicular region, the brain perceives the pain as originating from the left shoulder, a phenomenon known as referred pain. Restlessness is a key early clinical indicator of hypovolemia and shock, as the body's compensatory mechanisms trigger the sympathetic nervous system, leading to agitation and anxiety before overt changes in vital signs become apparent ^[1]. Given that the study by Cai and Li emphasizes clinical management focused on the "early detection of postoperative hemorrhage" through vigilant monitoring, a nurse's ability to interpret this subtle but critical sign is paramount ^[1].

The other assessment findings, while requiring ongoing evaluation, do not represent the same level of immediate threat to the client's survival.

- Mild incisional pain rated 4/10 is an expected finding 12 hours after major abdominal surgery. While pain management is an essential nursing function, it is not a priority over a potential hemorrhagic emergency. The priority is to rule out the life-threatening cause of the new shoulder pain.
- Absent bowel sounds in all quadrants is an expected physiological response to anesthesia and surgical manipulation of the bowel, known as a postoperative ileus. This is a common and anticipated finding in the first 24-48 hours post-laparotomy and does not signal an immediate life-threatening crisis.
- Urine output of 35 mL/hour falls slightly below the ideal threshold of >0.5 mL/kg/hr but is not critically oliguric. For a 65-year-old client, this could reflect mild relative hypovolemia, which is common postoperatively, or the early stages of fluid shifting. While it warrants continued close monitoring and potential fluid resuscitation, it is a less specific and later sign of hemorrhage than the sudden onset of referred shoulder pain and restlessness. The combination of restlessness and Kehr's sign points more directly to an acute, active bleeding process.

The significant risk of postoperative complications following splenectomy is well-documented. Research on splenectomy during complex procedures like cytoreductive surgery shows it is associated with substantial morbidity, including a higher rate of severe complications [2, 4]. While these studies focus on a specific surgical context, they underscore the inherent risks of splenic surgery, with hemorrhage being a primary concern due to the organ's vascular nature . The nurse's clinical judgment must prioritize the assessment finding that most directly signals this dangerous complication.