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Difficulty: HardReduction of Risk Potential

A nurse is evaluating a client who underwent a percutaneous coronary intervention (PCI) via the right femoral artery approach 4 hours ago. The femoral sheath has been removed and hemostasis was achieved. The client now reports a new onset of dull, aching pain in the right flank and lower back. Current vital signs are: blood pressure 96/60 mmHg, heart rate 114 bpm, and respiratory rate 20/min. The puncture site dressing is dry and intact, and the right pedal pulse is +2. Which of the following is the priority action by the nurse?

  1. Notify the rapid response team and prepare to administer intravenous isotonic fluids.Answer
  2. B
    Elevate the head of the bed to a 45-degree angle to relieve the lower back discomfort.
  3. C
    Administer the prescribed PRN oral analgesic to manage the expected post-procedural muscle ache.
  4. D
    Turn the client onto their left side to inspect the right flank for the presence of ecchymosis.

Answer

Notify the rapid response team and prepare to administer intravenous isotonic fluids.
The client is exhibiting classic signs of a retroperitoneal hemorrhage, a severe complication of femoral artery cannulation. Blood pooling in the retroperitoneal space causes flank and back pain, while the loss of circulating volume leads to tachycardia and hypotension. Because the bleeding is internal, the external dressing remains dry. The priority risk reduction action is to activate the rapid response team to obtain immediate medical assistance and prepare for fluid resuscitation to combat impending hypovolemic shock.

Step-by-Step Solution

1
Analyze the client's symptoms and vital signs.
The client has new right flank/back pain, hypotension (96/60 mmHg), and tachycardia (114 bpm).
These findings must be evaluated in the context of a recent femoral artery puncture.
2
Correlate the findings to potential post-procedure complications.
The combination of flank/back pain with signs of hypovolemia (tachycardia, hypotension) and a dry external puncture site strongly indicates internal bleeding, specifically a retroperitoneal hemorrhage.
Blood leaking from the femoral artery can track backward into the retroperitoneal space, causing back/flank pain and hidden blood loss.
3
Determine the priority risk reduction intervention.
The priority is to manage impending hypovolemic shock by calling for emergency assistance and initiating fluid resuscitation.
Prompt medical intervention and volume replacement are critical to stabilize the client's hemodynamic status and reduce the risk of mortality.

Key Concept

Recognition and immediate management of retroperitoneal hemorrhage following femoral artery instrumentation.
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Reduction of Risk Potential

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