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Zorluk: OrtaReduction of Risk Potential

A nurse is developing a plan of care for a client who will be returning to the medical-surgical unit following a percutaneous liver biopsy. Which of the following nursing actions should be included to reduce the risk of post-procedure complications? Select all that apply.

  1. Position the client in a right lateral position with a small towel placed under the puncture site.Cevap
  2. Maintain the client on strict bed rest for the first 2 to 4 hours after the procedure.Cevap
  3. C
    Delegate the initial post-procedure vital sign measurements to an unlicensed assistive personnel (UAP).
  4. D
    Elevate the head of the bed to a 45-degree angle immediately upon the client's arrival to the unit.
  5. E
    Monitor for a widening pulse pressure as an early physiological indicator of hemorrhage.
  6. Assess for a subtle, sustained increase in heart rate and respiratory rate as signs of hypovolemia.Cevap

Cevap

The appropriate interventions include positioning the client on their right side with a towel under the site, maintaining strict bed rest for 2 to 4 hours, and assessing for early indicators of shock such as a sustained increase in heart rate.
Following a percutaneous liver biopsy, the client is at high risk for significant bleeding due to the liver's dense vascularity. Positioning the client in a right lateral position with a small towel or pillow under the puncture site provides direct mechanical pressure to the liver capsule, which promotes hemostasis. Strict bed rest for 2 to 4 hours is necessary to minimize intra-abdominal pressure and prevent the dislodgment of forming clots. Finally, because internal bleeding can occur, the nurse must monitor for early compensatory signs of hypovolemia, most notably a subtle and sustained increase in heart rate and respiratory rate, which often precede an actual drop in blood pressure.

Adım Adım Çözüm

1
Identify the primary risk associated with a percutaneous liver biopsy.
The liver is a highly vascular organ, making severe internal hemorrhage the most significant immediate post-procedure complication.
Understanding the most dangerous complication dictates the priority preventative interventions.
2
Determine the appropriate mechanical interventions to prevent bleeding.
The nurse must position the client in a right lateral position to compress the liver against the chest wall and maintain strict bed rest.
Direct pressure and immobility facilitate clot formation at the highly vascular puncture site.
3
Evaluate the remaining systemic monitoring and delegation options.
Recognize that narrowing (not widening) pulse pressure and tachycardia indicate early shock, and recall that initial post-procedure assessments cannot be delegated.
The RN is responsible for detecting early subtle signs of physiological decompensation before delegating routine tasks.

Anahtar Kavram

Reduction of Risk Potential: Post-Liver Biopsy Care
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Reduction of Risk Potential

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