A nurse is evaluating a 64-year-old client who is 3 hours post-cardiac catheterization via the right femoral artery. The client reports new-onset, severe lower back pain and requests to have the head of the bed raised to eat a snack. The client's current vital signs are: blood pressure 98/60 mm Hg (baseline 135/82 mm Hg), heart rate 114/min, and respiratory rate 20/min. Which of the following actions should the nurse take first?
- Maintain the client in a flat, supine position with the right leg straight and inspect the right flank and groin.Answer
- BElevate the head of the bed to 45 degrees to relieve lumbar strain and administer prescribed analgesia.
- CReassure the client that back discomfort is an expected finding of prolonged bed rest and apply a warm compress.
- DContact the healthcare provider immediately to report the vital signs and prepare to draw an arterial blood gas.
Answer
The nurse must maintain the client in a flat, supine position with the right leg straight and immediately inspect the flank and groin for signs of bleeding.
The client's presentation of new-onset severe back pain, hypotension, and tachycardia shortly after a femoral artery procedure is highly suspicious for a retroperitoneal hemorrhage, where blood leaks backward into the retroperitoneal space. Maintaining the client in a flat, supine position with the affected leg completely straight is essential to prevent dislodging the clot at the femoral puncture site. The nurse must immediately assess the groin and flank for swelling, firmness, or ecchymosis (Grey Turner's sign) to confirm the bleeding and intervene effectively.
Step-by-Step Solution
Key Concept
Reduction of Risk Potential: Recognizing and preventing retroperitoneal hemorrhage post-cardiac catheterization