Multiple clients require evaluation on a high-acuity cardiovascular telemetry unit. Which clinical scenario dictates the most urgent need for the nurse's presence and immediate intervention?
- A client recovering from a percutaneous coronary intervention who suddenly reports severe lower back pain and exhibits a blood pressure drop from 130/82 mm Hg to 88/52 mm HgCevap
- BA client with chronic atrial fibrillation who has an irregular apical heart rate of 94 beats per minute and reports mild morning fatigue
- CA client diagnosed with right-sided heart failure who presents with 3+ pitting edema in both lower extremities and visible jugular venous distention
- DA client receiving a continuous intravenous infusion of furosemide for pulmonary edema whose urinary output was 400 mL over the past two hours
Cevap
The client recovering from a percutaneous coronary intervention who suddenly reports severe lower back pain and exhibits a significant drop in blood pressure requires the most immediate intervention.
The client who is post-percutaneous coronary intervention (PCI) is exhibiting classic signs of a retroperitoneal hemorrhage, a critical and potentially fatal complication of femoral arterial access. The sudden onset of severe back pain combined with a rapid drop in blood pressure indicates acute internal bleeding and hypovolemic shock. This represents an immediate threat to circulation (the 'C' in ABCs) and requires emergency interventions such as IV fluid boluses, applying pressure to the access site, and rapid provider notification.
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Anahtar Kavram
Prioritization using the Airway, Breathing, Circulation (ABC) framework and recognizing acute, unexpected changes over chronic, expected findings.