A practical nurse is assisting with the preparation of a client with severe hepatic cirrhosis who is scheduled for a bedside paracentesis. In what order should the nurse perform the following actions to minimize the risk of procedural complications, such as bladder perforation?
- 1Verify that the healthcare provider has obtained and documented informed consent.
- 2Instruct the client to completely empty their bladder in the restroom or bedside commode.
- 3Measure and record the client's baseline vital signs, body weight, and abdominal girth.
- 4Assist the client into a high Fowler's position or seat them upright on the side of the bed.
- 5Position the sterile paracentesis tray and collection receptacles on the bedside table.
Cevap
The correct sequence prioritizes administrative safety (verifying consent), followed by physiological risk reduction (emptying the bladder), obtaining accurate baseline data, optimal client positioning, and finally, establishing the sterile field.
Preparing for a paracentesis requires a strategic sequence to ensure client safety. Consent must be verified first. The client must then empty their bladder to drastically reduce the risk of a bladder perforation when the needle is inserted. Baseline vitals, weight, and abdominal girth must be measured immediately after voiding for accuracy. The client is then placed upright so gravity pools the ascites in the lower abdomen, safely away from vital organs. Finally, the sterile field is established.
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Anahtar Kavram
Client Preparation and Risk Reduction for Invasive Procedures (Paracentesis)