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Difficulty: HardReduction of Risk Potential

A 62-year-old client with advanced hepatic cirrhosis is 1 hour post-paracentesis, during which 4.54.5 liters of ascitic fluid were removed. The client reports feeling extremely dizzy and exhibits delayed cognitive responses. The nurse assesses the following clinical data:

Assessment ParameterBaselineCurrent Finding
Blood Pressure128/82128/82 mm Hg94/5894/58 mm Hg
Heart Rate7878 bpm114114 bpm
Respiratory Rate1616 breaths/min2222 breaths/min
Arterial Blood GasNot drawnpH 7.487.48, PaCO2_2 3030 mm Hg, HCO3−_3^- 2222 mEq/L

Which action should the nurse take to mitigate the risk of severe physiological decompensation?

  1. A
    Assist the client into a high-Fowler's position to maximize diaphragmatic excursion and correct the hypoventilation.
  2. B
    Instruct the client to breathe slowly into a paper bag to treat the uncompensated metabolic alkalosis.
  3. Initiate a prescribed intravenous albumin infusion and position the client supine with the lower extremities elevated.Answer
  4. D
    Palpate the abdominal quadrants to assess for an expanding internal hematoma before auscultating for returning bowel sounds.

Answer

The nurse should initiate the prescribed intravenous albumin infusion and position the client supine with the lower extremities elevated.
The client is exhibiting classic signs of Paracentesis-Induced Circulatory Dysfunction (PICD), a form of hypovolemic shock caused by massive fluid shifts following the rapid removal of large volumes of ascitic fluid. The priority is to restore intravascular volume and maintain cerebral perfusion. Administering intravenous albumin provides oncotic pressure to pull fluid back into the intravascular space, while positioning the client supine with elevated legs utilizes gravity to increase venous return to the heart.

Step-by-Step Solution

1
Analyze the client's vital sign trends and clinical presentation.
The significant drop in blood pressure, compensatory tachycardia, and dizziness indicate acute hypovolemic shock (Paracentesis-Induced Circulatory Dysfunction).
Rapid removal of large volumes of ascitic fluid causes massive fluid shifts from the intravascular space into the peritoneal cavity.
2
Evaluate the arterial blood gas (ABG) results.
A pH of 7.48 (alkalotic) and PaCO2 of 30 mm Hg (low) confirm uncompensated respiratory alkalosis.
The client is hyperventilating as a compensatory physiological response to tissue hypoxia and hypoperfusion.
3
Determine the priority nursing intervention.
The immediate priority is to restore intravascular volume and maintain cerebral and cardiac perfusion.
Untreated hypovolemic shock rapidly progresses to cardiovascular collapse and organ failure.
4
Select the most appropriate evidence-based action.
Administering intravenous albumin and placing the client supine with elevated legs is the correct choice.
Albumin acts as a volume expander by increasing plasma oncotic pressure, while the modified Trendelenburg position uses gravity to increase venous return.

Key Concept

Paracentesis-Induced Circulatory Dysfunction (PICD) Management
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Topics

Reduction of Risk Potential

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