A client arrives at the medical-surgical unit after undergoing a percutaneous liver biopsy. The registered nurse has completed the initial admission assessment and delegates ongoing care to the licensed practical nurse. Which actions are essential for the practical nurse to perform to minimize the risk of complications? Select all that apply.
- Position the client in a right lateral decubitus position using a small pillow or rolled towel under the costal margin.Answer
- BDocument a heart rate of 112 beats per minute and a blood pressure of 96/54 mm Hg as expected post-procedure anxiety.
- CDirect the unlicensed assistive personnel to obtain the immediate post-procedure vital signs and report any deviations.
- DAssist the client into a high-Fowler's position to maximize lung expansion and prevent atelectasis.
- Assess the client's vital signs every 15 minutes during the first hour and compare them to the pre-procedure baseline.Answer
- Inspect the biopsy puncture site and surrounding skin for overt bleeding or expanding hematoma during each assessment.Answer
Answer
The correct actions include positioning the client on the right side to apply pressure to the liver, monitoring vital signs every 15 minutes initially, and frequently inspecting the puncture site for bleeding.
Following a percutaneous liver biopsy, the primary risk is hemorrhage because the liver is a highly vascular organ. Positioning the client on the right side compresses the liver capsule against the chest wall, promoting hemostasis. Frequent vital sign monitoring (every 15 minutes for the first hour) and direct inspection of the puncture site are critical to rapidly identify signs of bleeding or hypovolemic shock.
Step-by-Step Solution
Key Concept
Reduction of Risk Potential: Post-Procedure Liver Biopsy Care