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Difficulty: MediumReduction of Risk Potential

A 64-year-old client is admitted to the progressive care unit 2 hours after a percutaneous coronary intervention (PCI) via the right femoral approach. During the focused assessment, which clinical findings indicate to the nurse that the client is experiencing a potential complication requiring immediate intervention? (Select all that apply.)

  1. The client reports a new, severe aching pain in the lower back and right flank.Answer
  2. The client's blood pressure decreases from 135/82135/82 mmHg to 105/76105/76 mmHg, and heart rate increases from 7878 bpm to 114114 bpm.Answer
  3. The right pedal pulse is graded as +1+1, while the left pedal pulse is graded as +2+2.Answer
  4. D
    The client is resting in a supine position with the head of the bed elevated 15∘15^\circ.
  5. E
    The client reports mild tenderness at the catheter insertion site upon palpation.
  6. F
    Arterial blood gas (ABG) results show a pH of 7.387.38, PaCO 2_2 of 4242 mmHg, and HCO 3−_3^- of 2424 mEq/L.

Answer

The findings requiring immediate intervention are new severe lower back and flank pain, a drop in blood pressure with tachycardia and narrowed pulse pressure, and a diminished right pedal pulse compared to the left.
Following a percutaneous coronary intervention via the femoral artery, the primary physiological risks are bleeding (including occult retroperitoneal bleeding) and arterial occlusion. The correct findings highlight severe complications: lower back or flank pain indicates retroperitoneal hemorrhage; tachycardia with a narrowing pulse pressure signals early hemorrhagic shock; and diminished pedal pulses indicate impaired distal perfusion from a clot or hematoma.

Step-by-Step Solution

1
Analyze the client's risk profile based on the procedure.
The client underwent a right femoral PCI, placing them at high risk for arterial bleeding, hematoma formation, and retroperitoneal hemorrhage.
Identifying procedure-specific risks directs the focused physical assessment.
2
Evaluate the vital signs and subjective pain reports for signs of bleeding.
The client demonstrates narrowing pulse pressure with tachycardia, and new ipsilateral flank pain.
These are primary indicators of occult bleeding (retroperitoneal hemorrhage) and early shock.
3
Assess peripheral perfusion distal to the puncture site.
The right pedal pulse is weaker than the left.
Asymmetry in pulses distal to the puncture site suggests arterial compromise requiring immediate evaluation.
4
Differentiate between expected post-procedural findings and abnormal complications.
Mild site tenderness, a low-Fowler's position, and normal ABGs are expected or therapeutic.
Prioritizing true complications prevents unnecessary interventions and ensures immediate life-saving actions are taken when indicated.

Key Concept

Post-procedural assessment and identification of life-threatening complications (retroperitoneal bleeding, shock, and arterial occlusion) following femoral artery access.
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Reduction of Risk Potential

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