An adult client with advanced hepatic cirrhosis has just been transferred back to the medical-surgical unit after a therapeutic paracentesis that removed 4.5 liters of ascitic fluid. To minimize the risk of severe physiological decompensation, which of the following nursing actions should be included in the client's immediate plan of care? Select all that apply.
- Administer the prescribed intravenous albumin infusion over the next several hours.Answer
- Assess the client closely for a narrowing pulse pressure, restlessness, and an increasing heart rate.Answer
- Inspect the abdominal puncture site frequently for evidence of continuous fluid leakage or bleeding.Answer
- DPlace the client in the Trendelenburg position if the systolic blood pressure drops below baseline.
- EAttribute a sustained resting heart rate of 118 beats per minute primarily to procedure-related pain.
- FDelegate the initial post-procedure vital sign assessments and mental status checks to an unlicensed assistive personnel (UAP).
Answer
The correct actions are to administer the prescribed intravenous albumin, closely assess for early signs of hypovolemic shock (such as narrowing pulse pressure and tachycardia), and frequently inspect the puncture site for bleeding or leakage.
Removing large amounts of ascitic fluid rapidly decreases abdominal pressure, causing blood vessels to suddenly expand and fluid to shift out of the intravascular space. This places the client at a severe risk for hypovolemic shock. Administering albumin replaces oncotic pressure to hold fluid in the vessels. Monitoring for a narrowing pulse pressure and tachycardia allows the nurse to catch shock in its early compensatory phase. Checking the puncture site ensures that the client is not actively bleeding or losing further fluid.
Step-by-Step Solution
Key Concept
Post-procedure Hemodynamic Monitoring and Complication Prevention