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Soru

Zorluk: ZorReduction of Risk Potential

A nurse is developing a plan of care for a 62-year-old client who has just been admitted to the telemetry unit following a left-sided cardiac catheterization via the femoral approach. The client has a documented history of severe chronic obstructive pulmonary disease (COPD). Which of the following nursing actions are appropriate to reduce the risk of potential complications? (Select all that apply)

  1. Compare the quality of the left pedal pulse to the right and monitor the groin insertion site for swelling.Cevap
  2. B
    Elevate the head of the bed to a 60-degree angle to optimize respiratory expansion due to the client's COPD.
  3. Maintain the client on strict bed rest with the left leg extended and immobilized for the prescribed duration.Cevap
  4. D
    Notify the rapid response team for an arterial blood gas result showing a pH of 7.36 and PaCO2 of 52 mm Hg.
  5. Instruct the client to apply firm manual pressure over the left groin insertion site when coughing or sneezing.Cevap
  6. F
    Perform deep abdominal palpation before auscultating bowel sounds to quickly assess for retroperitoneal hemorrhage.

Cevap

The correct nursing actions to reduce complications include comparing bilateral pedal pulses while monitoring for swelling, maintaining the affected leg straight and immobilized, and instructing the client to apply pressure to the groin site when coughing.
Following a femoral cardiac catheterization, the highest priority is preventing arterial hemorrhage and maintaining distal tissue perfusion. Comparing pedal pulses and monitoring the site ensures early detection of neurovascular compromise or hematoma. Keeping the leg extended and immobilized prevents mechanical disruption of the arterial clot. Finally, instructing the client to apply manual pressure when coughing provides necessary counter-pressure to prevent bleeding caused by sudden spikes in intra-abdominal pressure.

Adım Adım Çözüm

1
Identify the primary physiological risks associated with a femoral approach cardiac catheterization.
The client is at high risk for arterial bleeding, hematoma formation, retroperitoneal hemorrhage, and peripheral neurovascular compromise.
The femoral artery is a large, high-pressure vessel; preventing clot disruption is paramount immediately post-procedure.
2
Determine the appropriate physical positioning and client education to mitigate these bleeding risks.
The affected leg must remain extended and immobilized, the head of the bed should be kept at 30 degrees or flatter, and the client must apply manual counter-pressure during Valsalva maneuvers like coughing.
Bending the leg or raising the head of the bed sharply increases mechanical stress on the arterial puncture site.
3
Evaluate the client's comorbidity (COPD) against the post-procedure restrictions.
While clients with severe COPD typically benefit from a high Fowler's position, doing so post-cardiac catheterization is contraindicated. Additionally, a compensated ABG showing elevated PaCO2 and a normal pH is expected, not an acute crisis.
Routine interventions for chronic conditions must be carefully balanced against acute post-operative safety protocols to avoid creating life-threatening complications.
4
Review general assessment standards for detecting internal complications.
Physical assessment of the abdomen for retroperitoneal bleeding must strictly follow the standard sequence of inspection, auscultation, and then palpation.
Altering the assessment sequence can lead to inaccurate clinical findings, such as artificially stimulated bowel sounds.

Anahtar Kavram

Post-procedure care and complication prevention following femoral cardiac catheterization, integrating competing priorities from chronic comorbidities.
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Reduction of Risk Potential

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