A practical nurse (PN) is reviewing the electronic health record (EHR) of an adult client who underwent a right femoral cardiac catheterization 3 hours ago.
| Time | Clinical Data |
|---|---|
| 0900 (Pre-procedure) | Blood Pressure: 142/86 mm Hg Heart Rate: 78/min Pedal Pulses: +2 bilaterally |
| 1200 (2 hr Post) | Blood Pressure: 128/78 mm Hg Heart Rate: 84/min Right groin dressing: Dry and intact |
| 1300 (3 hr Post) | Blood Pressure: 104/62 mm Hg Heart Rate: 116/min Client reports a new, persistent ache in the lower back. |
Based on these findings, which of the following is the priority action for the practical nurse?
- Notify the registered nurse (RN) immediately regarding the vital signs and pain.Cevap
- BAdminister the prescribed as-needed (PRN) oral analgesic for the back pain.
- CAssist the client into a side-lying position to inspect the posterior skin.
- DVerify the client's most recent coagulation panel in the electronic health record.
Cevap
The priority action is to immediately notify the registered nurse (RN) regarding the assessment findings, as they strongly indicate a developing retroperitoneal hemorrhage.
The client is exhibiting classic signs of a retroperitoneal hemorrhage, a severe complication of femoral artery access. When the posterior wall of the femoral artery leaks, blood tracks backward into the retroperitoneal space. Because the blood pools internally, the anterior groin dressing will often remain dry and intact. The expanding hematoma puts pressure on the surrounding nerves, causing persistent lower back or flank pain. This localized pain, combined with the systemic signs of developing hypovolemic shock (hypotension and tachycardia), constitutes a life-threatening emergency. The practical nurse must immediately escalate these findings to the RN or healthcare provider for advanced medical intervention.
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Anahtar Kavram
Recognition and escalation of retroperitoneal hemorrhage following femoral cardiac catheterization