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Difficulty: Very hardReduction of Risk Potential

A 68-year-old client with a history of chronic obstructive pulmonary disease (COPD) is admitted to the cardiac intensive care unit following a percutaneous coronary intervention (PCI) with stent placement via the right femoral artery. The client is receiving a continuous intravenous heparin infusion and a glycoprotein IIb/IIIa inhibitor. To reduce the risk of severe, life-threatening complications, which of the following assessment findings would require the nurse to intervene immediately? (Select all that apply.)

  1. The client reports a sudden onset of severe, unrelenting lower back and flank pain.Answer
  2. The client's right pedal pulse is currently detectable only via Doppler ultrasound, whereas it was manually palpable on admission.Answer
  3. The client's blood pressure changes from 138/82 mm Hg to 108/90 mm Hg, accompanied by a heart rate increase from 78 to 118 beats/minute.Answer
  4. D
    The client's continuous telemetry monitor displays occasional, isolated unifocal premature ventricular contractions (PVCs) at a rate of 2 per minute.
  5. E
    The client is observed resting in a supine position with the head of the bed elevated to 15 degrees and the right leg kept straight.
  6. F
    An arterial blood gas (ABG) analysis on room air reveals a pH of 7.36, PaCO2 of 49 mm Hg, and HCO3- of 28 mEq/L.

Answer

The findings that require immediate intervention are the sudden onset of severe lower back and flank pain, the diminished right pedal pulse (now only Doppler-detectable), and the vital signs demonstrating a narrowing pulse pressure with tachycardia.
The correct findings indicate acute, life-threatening complications of a percutaneous coronary intervention via a femoral approach. Sudden, unrelenting lower back and flank pain is a hallmark sign of a retroperitoneal hemorrhage, a critical bleeding complication. A pulse that was manually palpable and is now only detectable by Doppler indicates significantly decreased perfusion, suggesting an arterial occlusion or a rapidly expanding hematoma compromising blood flow. A narrowing pulse pressure (e.g., from 56 mm Hg to 18 mm Hg) coupled with tachycardia is an early, compensatory physiological response to hypovolemic shock, likely due to internal bleeding. All three findings require immediate nursing intervention and physician notification to prevent irreversible ischemic or hemorrhagic damage.

Step-by-Step Solution

1
Analyze the clinical scenario and the client's risk profile.
The client is post-PCI via the femoral artery and is heavily anticoagulated (heparin and a glycoprotein IIb/IIIa inhibitor), placing them at extreme risk for bleeding (hematoma, retroperitoneal hemorrhage) and arterial occlusion.
Identifying the highest-risk complications directs the assessment priorities.
2
Evaluate the presenting symptoms and physical assessment findings for acute decompensation.
Sudden flank pain indicates retroperitoneal bleeding. A diminished pedal pulse indicates acute arterial compromise. Both are medical emergencies.
Early recognition of tissue ischemia and internal bleeding is critical for limb and life preservation.
3
Interpret the vital sign trends for early indicators of shock.
The change in blood pressure from 138/82 to 108/90 reveals a significantly narrowed pulse pressure (from 56 mm Hg to 18 mm Hg). Combined with a heart rate jumping from 78 to 118, this demonstrates early compensatory hypovolemic shock.
Compensatory mechanisms can mask a falling systolic blood pressure; narrowing pulse pressure and tachycardia are earlier, more subtle signs of severe blood loss.
4
Differentiate expected or stable findings from acute emergencies.
Occasional PVCs are expected reperfusion rhythms. The 15-degree supine position is correct for femoral access site care, despite the COPD history. The ABG shows a compensated baseline for COPD, not an acute failure.
Intervening on expected baseline findings wastes critical time and can cause harm (e.g., elevating the head of the bed to treat the COPD could cause the femoral artery to bleed).

Key Concept

Prioritization of early hemorrhagic and ischemic complications following endovascular procedures
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Topics

Reduction of Risk Potential

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