A practical nurse is preparing an adult client with severe hepatic cirrhosis and ascites for a bedside abdominal paracentesis. Arrange the following pre-procedure actions in the correct chronological sequence to minimize the risk of procedural complications.
- 1Verify that the informed consent document has been signed and placed in the client's medical record.
- 2Instruct the client to void and completely empty their bladder.
- 3Obtain the client's baseline vital signs, weight, and abdominal girth.
- 4Assist the client into a high-Fowler's position or sitting upright on the edge of the bed.
- 5Set up the sterile paracentesis tray and supplies at the bedside.
Answer
The correct sequence is: Verify informed consent, instruct the client to empty their bladder, obtain baseline measurements, position the client upright, and finally set up the sterile tray.
The correct sequence prioritizes legal readiness, then proceeds to crucial physiological risk reduction. The client must void first to prevent accidental bladder perforation by the trocar. Once the bladder is empty, an accurate baseline weight, abdominal girth, and vital signs can be obtained. The client is then positioned upright to pool the fluid, and the sterile tray is opened last to maintain strict asepsis immediately prior to insertion.
Step-by-Step Solution
Key Concept
Risk reduction during paracentesis preparation involves preventing bladder perforation, establishing baselines for shock detection, and ensuring proper gravity pooling of fluid.