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Difficulty: MediumBasic Care and Comfort

A client on a telemetry unit requires strict bed rest after undergoing a percutaneous coronary intervention via the right femoral artery. During the immediate post-procedure period, the client reports a mild lower back ache and needs personal hygiene care. Which nursing interventions are appropriate for this client? (Select all that apply.)

  1. A
    Elevate the head of the bed to a 45-degree angle to decrease pressure on the lumbar spine.
  2. B
    Place a rolled blanket beneath the right knee to alleviate tension in the lower back muscles.
  3. C
    Ask the unlicensed assistive personnel (UAP) to evaluate the characteristics of the reported back pain.
  4. Maintain the right leg in a straight position while log-rolling the client to the left side for back care.Answer
  5. Instruct the client in deep breathing and guided imagery to help manage the back discomfort.Answer
  6. Apply a protective moisture barrier ointment to the sacral area after cleansing the skin.Answer

Answer

The appropriate interventions include keeping the right leg straight while log-rolling to the left side, teaching relaxation techniques for comfort, and applying barrier cream to the sacrum.
Appropriate basic care for a client post-femoral catheterization involves adapting hygiene and comfort measures to strict positioning limits. The client must be log-rolled to the unaffected side while keeping the affected limb straight to prevent bleeding. Providing non-pharmacologic comfort and applying skin barrier cream are essential, safe nursing actions that maintain physiological integrity during bed rest.

Step-by-Step Solution

1
Analyze the client's current clinical constraints
The client has a right femoral artery puncture site, requiring strict bed rest with the right leg kept completely straight and the head of the bed elevated no more than 30 degrees.
To prevent bleeding or hematoma formation at the high-pressure arterial access site.
2
Evaluate hygiene interventions
Hygiene can be safely provided by log-rolling the client to the left (unaffected) side while ensuring the right leg remains extended. Barrier cream should be applied to protect the sacral skin from breakdown.
Basic care must be adapted to align with post-procedure mobility restrictions.
3
Evaluate pain management and assessment interventions
Non-pharmacologic methods like deep breathing should be used for comfort. The RN must personally assess the back pain instead of delegating it, as it could indicate a complication.
Pain assessment requires clinical judgment, especially to rule out retroperitoneal hemorrhage.

Key Concept

Basic care and positioning modifications following femoral arterial access
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Topics

Basic Care and Comfort

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