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Difficulty: HardReduction of Risk Potential

An adult client was transferred to the telemetry unit following a percutaneous coronary intervention (PCI) utilizing a right femoral approach. Baseline vital signs at admission were blood pressure 134/84 mmHg and heart rate 72 bpm. Two hours later, the client complains of a continuous, dull ache in the right flank and lower back. The current vital signs demonstrate a blood pressure of 102/60 mmHg and a heart rate of 110 bpm. Examination of the right femoral insertion site reveals a dry, intact dressing with no visible swelling or external bleeding. Based on these clinical findings, what is the most appropriate initial action by the nurse?

  1. A
    Elevate the head of the bed to 45 degrees to alleviate the lower back discomfort.
  2. B
    Administer the prescribed as-needed opioid analgesic to manage the flank pain.
  3. C
    Conduct a comprehensive neurovascular assessment of the right distal extremity.
  4. Alert the rapid response team and prepare to initiate intravenous fluid resuscitation.Answer

Answer

Alert the rapid response team and prepare to initiate intravenous fluid resuscitation.
The correct answer addresses a severe, life-threatening complication. A retroperitoneal hemorrhage occurs when blood leaks from the femoral artery puncture site backward into the retroperitoneal space. Because the bleeding is internal, the external groin dressing will appear perfectly dry and intact. The classic clinical presentation includes ipsilateral flank or back pain, hypotension, and tachycardia. Immediate activation of the rapid response team and preparation for fluid resuscitation are critical to stabilize the client's hemodynamics.

Step-by-Step Solution

1
Analyze the client's vital sign trends.
Blood pressure decreased from 134/84 to 102/60 mmHg, and heart rate increased from 72 to 110 bpm.
These changes indicate early hypovolemic shock, likely due to acute blood loss.
2
Evaluate the localized symptoms in the context of the recent procedure.
The client has new-onset right flank and lower back pain following a right femoral artery puncture.
Blood leaking from the femoral artery can track backward into the retroperitoneal space, causing severe back or flank pain without visible bleeding at the skin surface.
3
Determine the priority intervention.
The most appropriate action is to notify the medical emergency team for immediate systemic support.
Retroperitoneal hemorrhage is a life-threatening emergency that requires rapid volume replacement and potential surgical or endovascular repair.

Key Concept

Early Recognition of Retroperitoneal Hemorrhage Post-PCI
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Topics

Reduction of Risk Potential

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