A nurse is preparing a client with advanced cirrhosis for a therapeutic bedside paracentesis to relieve severe ascites. To minimize the risk of procedural complications and ensure physiological stability, arrange the following nursing actions in the correct chronological sequence.
- 1Instruct the client to completely empty their bladder to prevent accidental organ puncture.
- 2Obtain the client's baseline vital signs, body weight, and abdominal girth.
- 3Assist the client into a high-Fowler's position or sitting upright on the edge of the bed.
- 4Monitor the client for signs of hypovolemia and hypotension during ascitic fluid removal.
- 5Apply a sterile pressure dressing and administer prescribed intravenous albumin.
Cevap
The correct sequence prioritizes preventing mechanical organ injury first, establishing accurate post-void baselines second, positioning for procedural safety third, executing intra-procedural hemodynamic monitoring fourth, and providing post-procedural circulatory support last.
The priority sequence for a paracentesis focuses on a deliberate progression of risk reduction: preventing mechanical organ injury (voiding), establishing accurate clinical baselines (weighing post-void), ensuring safe anatomical needle insertion (upright positioning), monitoring for intra-procedural shock (hemodynamic assessments), and preventing post-procedural circulatory collapse (albumin administration).
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Anahtar Kavram
Paracentesis Risk Reduction and Sequential Complication Management