Two hours after a right femoral cardiac catheterization, a client reports a new onset of dull lower back pain. The practical nurse notes the right groin dressing is dry and intact with no visible hematoma, and distal pulses remain equal bilaterally. The client's vital signs are: temperature 98.6°F (37°C), heart rate 108/min, respirations 18/min, and blood pressure 104/62 mm Hg. Baseline vital signs prior to the procedure were heart rate 74/min and blood pressure 128/78 mm Hg. What is the most appropriate next action for the practical nurse?
- Notify the supervising registered nurse immediately regarding the assessment changes.Cevap
- BAdminister the prescribed as-needed analgesic to treat the client's back pain.
- CDocument the assessment findings in the health record and continue routine monitoring.
- DApply firm manual pressure directly above the right femoral insertion site.
Cevap
The most appropriate action is to notify the supervising registered nurse immediately regarding the assessment changes.
The client is exhibiting signs of retroperitoneal bleeding, a critical and potentially life-threatening complication of femoral cardiac catheterization. The combination of new-onset back pain (due to blood pooling in the retroperitoneal space) and shifting vital signs (tachycardia and borderline hypotension compared to baseline) strongly indicates internal hemorrhage, even when the external insertion site appears dry and intact. The practical nurse must immediately escalate these findings to the registered nurse for urgent medical evaluation.
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Recognition and Escalation of Post-Procedural Hemorrhage