# A nurse is caring for a client who underwent a splenectomy 24 hours ago following severe abdominal trauma. When developing the plan of care, which nursing intervention should be the highest priority?

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> subject: Adult Health

## 문제

A nurse is caring for a client who underwent a splenectomy 24 hours ago following severe abdominal trauma. When developing the plan of care, which nursing intervention should be the highest priority?

## 보기

1. Monitor for signs of infection and administer prophylactic antibiotics **✔ 정답**
2. Encourage early ambulation to prevent deep vein thrombosis
3. Assess pain level and administer analgesics
4. Monitor intake and output to prevent fluid overload

**정답: 1**

## 해설

After splenectomy, infection prevention is the highest priority due to loss of immune function and risk of overwhelming post-splenectomy infection (OPSI). Other interventions are important but secondary.

## 심화 해설

Understanding the Priority: Post-Splenectomy Sepsis Risk

The highest priority for a client 24 hours after splenectomy is to monitor for signs of infection and administer prophylactic antibiotics. This intervention directly addresses the most immediate and lethal threat following the removal of the spleen: overwhelming post-splenectomy infection (OPSI).

The Pathophysiology of the Risk

The spleen is the primary site for filtering blood and mounting an early immune response against encapsulated bacteria. After a splenectomy, the body loses its most efficient mechanism for clearing organisms like Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis from the bloodstream. Without splenic macrophages to phagocytize these pathogens, a localized infection can rapidly progress to fulminant bacteremia and septic shock. This condition, OPSI, carries a high mortality rate, and its onset can be devastatingly swift, often within the first 24 to 48 hours postoperatively .

Why Other Interventions Are Lower Priority

While all options represent valid components of postoperative care, they do not address the most immediate life threat. The nursing process requires prioritization based on the ABCs and the risk of rapid clinical deterioration.

*   Pain management (Option 3): Assessing and treating pain is essential for comfort, pulmonary toilet, and early mobility. However, pain is an expected postoperative finding and does not pose the same immediate threat of mortality as OPSI.

*   Early ambulation (Option 2): Preventing deep vein thrombosis is a key safety goal, but the risk of a thromboembolic event developing into a life-threatening emergency within the first 24 hours is generally lower than the risk of fulminant sepsis in an asplenic patient.

*   Fluid balance (Option 4): Monitoring intake and output is a standard postoperative intervention to assess renal function and fluid status. While important, fluid overload is a slower-developing complication compared to the hyperacute nature of OPSI.

Clinical Application and Prophylaxis

The clinical significance of this risk is so profound that prevention through prophylactic antibiotics is a cornerstone of care. The provided evidence highlights a case of recurrent pneumococcal OPSI, underscoring that the risk is not only immediate but lifelong . For the nurse at the bedside 24 hours post-splenectomy, the priority is to implement the prophylactic orders and vigilantly monitor for the earliest signs of infection, such as a subtle temperature elevation, chills, tachycardia, or a sense of impending doom, as these can be the only warning before rapid decompensation. The administration of prophylactic antibiotics is a time-sensitive intervention that directly mitigates the primary mechanism of death in this population .

## 임상 시나리오

Clinical Priority: Post-Splenectomy Sepsis Prevention

The highest priority in the first 24-48 hours post-splenectomy is preventing overwhelming post-splenectomy infection (OPSI). The loss of splenic macrophages eliminates the primary defense against encapsulated bacteria (S. pneumoniae, H. influenzae, N. meningitidis), allowing a localized infection to rapidly progress to fulminant septic shock with high mortality.

Essential Nursing Interventions

- **Continuous Surveillance:** Monitor vital signs every 1-2 hours for early signs of sepsis, including fever, chills, tachycardia, tachypnea, and hypotension. Assess for subtle changes in mental status or skin perfusion.

- **Prophylactic Antibiotics:** Administer prescribed broad-spectrum antibiotics on time without delay. This is a critical medical intervention to provide immediate protection while the immune system adapts.

- **Wound and Drain Assessment:** Inspect the surgical incision and any drain sites for erythema, purulent drainage, or increased tenderness, which could indicate a localized source of infection.

- **Patient Education:** Begin teaching the patient about their lifelong increased infection risk, the need for prompt medical attention for any fever, and the importance of future vaccinations (pneumococcal, meningococcal, Hib) and potential prophylactic antibiotics before dental procedures.

Rationale for Prioritization

Using the nursing process, the risk for infection and potential for rapid progression to septic shock takes precedence over other postoperative concerns. While pain management, early ambulation, and fluid balance are important, they are secondary to the immediate, lethal threat of OPSI. A delay in recognizing or preventing infection can be fatal within hours.

## 핵심 개념

- **Overwhelming Post-Splenectomy Infection (OPSI)** — A rapidly progressive, life-threatening infection occurring after splenectomy, primarily caused by encapsulated bacteria, due to the loss of splenic immune function.
- **Splenectomy** — Surgical removal of the spleen, resulting in a lifelong increased risk of severe bacterial infections due to the organ's role in filtering pathogens and producing antibodies.
- **Encapsulated Bacteria** — Bacteria with a polysaccharide capsule that protects them from phagocytosis; the spleen is critical for their clearance. Key examples include Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis.

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