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Difficulty: MediumPhysiological Adaptation

During a routine hourly check, a client recovering from a right femoral percutaneous coronary intervention (PCI) complains of a newly developed, constant lower back ache. The insertion site dressing remains clean and dry. A review of the continuous vital signs monitor reveals a heart rate of 106 bpm and a blood pressure of 108/84 mm Hg, which is a change from a baseline of 72 bpm and 132/78 mm Hg recorded two hours prior.

Which action should the nurse execute first?

  1. A
    Administer the prescribed as-needed intravenous opioid analgesic
  2. B
    Elevate the head of the bed to 45 degrees to decrease tension on the lower back
  3. Assess the right flank and posterior lower back for ecchymosis or swellingAnswer
  4. D
    Palpate the right pedal and posterior tibial pulses to verify adequate perfusion

Answer

The nurse should first assess the right flank and posterior lower back for ecchymosis or swelling to evaluate for a retroperitoneal hemorrhage.
The combination of new-onset lower back pain and vital sign changes (tachycardia and a narrowed pulse pressure from 54 mm Hg to 24 mm Hg) following a femoral percutaneous coronary intervention strongly suggests a retroperitoneal hemorrhage. Because blood can pool in the retroperitoneal space without visible bleeding at the anterior insertion site, the nurse's immediate priority is to assess the flank and posterior back for swelling or ecchymosis to confirm the source of the suspected hypovolemic shock.

Step-by-Step Solution

1
Analyze the client's symptoms and vital sign changes.
The client has new lower back pain, tachycardia, and a narrowing pulse pressure (baseline pulse pressure was 54 mm Hg, current is 24 mm Hg).
Recognizing deviations from baseline vital signs is essential to identify early physiological deterioration and compensatory shock mechanisms.
2
Correlate the findings with the recent procedure.
The client had a femoral PCI. Bleeding from the femoral artery can track backward into the retroperitoneal space, causing back pain without visible bleeding at the groin site.
Connecting the procedure type with specific localized symptoms helps pinpoint the likely complication.
3
Determine the highest priority action.
The nurse must visually inspect the flank and back (looking for Grey Turner's sign) to confirm the suspicion of retroperitoneal bleeding.
Assessment of a new, life-threatening complication must precede routine interventions or symptom management.

Key Concept

Recognition of early hemorrhagic shock and retroperitoneal bleeding post-PCI
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Physiological Adaptation

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