A nurse is caring for a client who underwent a percutaneous coronary intervention (PCI) via the right femoral artery 3 hours ago. The client's current vital signs are: blood pressure 104/62 mmHg (baseline 128/78 mmHg) and heart rate 102 bpm (baseline 76 bpm). The client reports new-onset moderate right flank pain. Which of the following is the most appropriate initial nursing action?
- Assess the client's retroperitoneal area for firmness or ecchymosis and maintain strict supine positioning.Cevap
- BElevate the head of the bed to 45 degrees to promote client comfort and reduce flank strain.
- CAdminister a prescribed oral analgesic for the pain and document the findings as expected post-procedure discomfort.
- DDelegate the unlicensed assistive personnel (UAP) to monitor the client's vital signs every 15 minutes.
Cevap
The most appropriate initial action is to assess the client's retroperitoneal area for firmness or ecchymosis and maintain strict supine positioning.
The client's decreasing blood pressure, increasing heart rate, and new-onset flank pain strongly suggest retroperitoneal bleeding, a life-threatening complication of femoral artery access. The immediate priority is to assess for further signs of bleeding (such as ecchymosis or a hematoma) while keeping the client strictly supine to prevent tension on the arterial puncture site.
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Anahtar Kavram
Early recognition and risk mitigation of retroperitoneal hemorrhage following femoral artery catheterization.