# A nurse is assessing a 35-year-old patient 2 days after laparoscopic sleeve gastrectomy. Which assessment finding would be the priority concern requiring immediate intervention?

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## 문제

A nurse is assessing a 35-year-old patient 2 days after laparoscopic sleeve gastrectomy. Which assessment finding would be the priority concern requiring immediate intervention?

## 보기

1. Patient reports mild incisional pain rated 4/10
2. Patient has consumed 30 mL of clear liquids in the past 4 hours
3. Patient's blood pressure is 110/70 mmHg with heart rate of 88 bpm
4. Patient reports severe left shoulder pain with difficulty breathing **✔ 정답**

**정답: 4**

## 해설

Severe left shoulder pain with difficulty breathing suggests pneumoperitoneum or anastomotic leak, requiring immediate intervention for potential hypoxia. Other findings (mild pain, limited intake, stable vitals) are normal post-op.

## 심화 해설

Clinical Reasoning & Priority Setting

This question tests your ability to recognize a potentially life-threatening postoperative complication versus expected findings after laparoscopic sleeve gastrectomy (LSG). The correct answer is Option 4.

Analysis of the Correct Answer

Severe left shoulder pain with difficulty breathing is the priority concern. While left shoulder pain can be a benign referred pain from diaphragmatic irritation by carbon dioxide used during laparoscopy, its combination with dyspnea in the early postoperative period is a red flag. This presentation should immediately raise suspicion for a diaphragmatic irritation or compression caused by a subphrenic collection, such as a hematoma or abscess, or a pleural effusion. As noted in the literature, uncommon but serious complications like splenic hematoma can occur after LSG, and these may be associated with a left-sided pleural effusion, leading to respiratory compromise [1]. The underlying pathophysiology involves the close anatomical proximity of the spleen to the gastric fundus; operative manipulation or thermal injury can result in splenic trauma and delayed bleeding. This blood can track superiorly, irritating the diaphragm and causing a sympathetic pleural effusion, which manifests as shoulder pain (Kehr's sign) and dyspnea. This finding signals a need for immediate diagnostic evaluation, such as a CT scan, and potential surgical intervention [1].

Analysis of Incorrect Options

- Option 1: Mild incisional pain rated 4/10 is an expected finding 2 days after a laparoscopic abdominal surgery. While it requires ongoing assessment and pain management, it does not signal an acute, life-threatening change in status.

- Option 2: Consuming 30 mL of clear liquids over 4 hours is a low volume, but it is an acceptable and expected intake during the initial postoperative phase as the patient slowly advances their diet. This is not an immediate concern compared to a sign of hemorrhage or respiratory distress.

- Option 3: A blood pressure of 110/70 mmHg with a heart rate of 88 bpm falls within normal limits for an adult. These vital signs do not indicate hemodynamic instability and are not the priority.

NCLEX-RN Clinical Application

For the NCLEX, a sudden onset of severe shoulder pain with respiratory difficulty after a procedure like LSG must be treated as a surgical emergency until proven otherwise. Your priority nursing action is to assess the patient's airway and breathing, apply oxygen, notify the surgeon immediately, and prepare the patient for urgent diagnostic imaging (such as a CT scan) to rule out a splenic injury or other source of intra-abdominal bleeding that is causing diaphragmatic irritation and pleural effusion [1,2]. While postoperative leaks and strictures are more commonly discussed complications of LSG, the provided evidence highlights that rare hemorrhagic events like splenic hematoma can present insidiously and require a high index of suspicion for timely recognition and management [1,2,3].References (research sources)

- [1]Pleural Effusion in a Patient With Splenic Hematoma Following Sleeve Gastrectomy: A Case Report.Case reportAbu-Ghazal S, Alromi A. (2026) · DOI: 10.7759/cureus.108048

## 임상 시나리오

Post-Bariatric Surgery Emergency AssessmentRecognizing Life-Threatening Complications vs. Expected Findings
Severe left shoulder pain with dyspnea after laparoscopic sleeve gastrectomy is a red flag for diaphragmatic irritation from a subphrenic collection (e.g., hematoma, abscess) or pleural effusion.

This presentation can indicate a splenic injury or staple line leak. The close proximity of the spleen to the gastric fundus makes it vulnerable to operative trauma. Blood tracking to the diaphragm causes Kehr's sign and respiratory compromise.

CautionDo not dismiss shoulder pain as simple referred gas pain. Immediate diagnostic evaluation with a CT scan and surgical consultation is required. Monitor for tachycardia and hypotension, which are late signs of hemorrhagic shock.

## 핵심 개념

- **Kehr's Sign** — Referred pain to the left shoulder caused by diaphragmatic irritation, often from intra-abdominal bleeding or free air.
- **Laparoscopic Sleeve Gastrectomy** — A restrictive bariatric surgery removing a portion of the stomach, with risks including staple line leak, bleeding, and splenic injury.
- **Diaphragmatic Irritation** — Stimulation of the phrenic nerve due to blood, pus, or air under the diaphragm, commonly presenting with shoulder tip pain.
- **Subphrenic Collection** — An accumulation of fluid such as blood or pus below the diaphragm, a potential postoperative complication causing respiratory distress.

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