During hourly rounds, a practical nurse evaluates a client who underwent a percutaneous coronary intervention via the right femoral approach 3 hours ago. The client's current vital signs are blood pressure 108/62 mm Hg, heart rate 112 beats/min, and respirations 20 breaths/min. Baseline vital signs obtained immediately post-procedure were blood pressure 135/78 mm Hg, heart rate 78 beats/min, and respirations 16 breaths/min. The client reports a new onset of dull, aching back pain. The right groin dressing appears dry and intact. Which action should the nurse take next?
- Notify the supervising registered nurse immediately regarding the vital sign trends and reported painAnswer
- BDocument the findings in the medical record and reassess the client's vital signs in 30 minutes
- CAdminister the prescribed as-needed oral analgesic to treat the client's back pain
- DIncrease the rate of the continuous intravenous fluid infusion to correct the client's hypotension
Answer
The nurse should immediately notify the supervising registered nurse about the vital sign changes and the back pain, as these indicate a potential retroperitoneal hemorrhage.
Retroperitoneal hemorrhage is a severe and potentially life-threatening complication of a percutaneous coronary intervention performed via the femoral artery. Because the bleeding occurs internally into the retroperitoneal space, the external groin dressing often remains dry and intact. The classic manifestations include a new onset of lower back or flank pain accompanied by signs of early hypovolemic shock, such as tachycardia and a dropping blood pressure. The practical nurse must recognize these critical trends and immediately notify the registered nurse or healthcare provider to initiate life-saving interventions.
Step-by-Step Solution
Key Concept
Monitoring for and escalating signs of complications following invasive procedures (Reduction of Risk Potential).