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Zorluk: ZorReduction of Risk Potential

A charge nurse is evaluating the care of a client who returned to the unit following a large-volume paracentesis for severe ascites. Which of the following assessment findings or nursing actions require IMMEDIATE follow-up to prevent physiological decompensation? (Select all that apply.)

  1. A heart rate of 118 beats per minute with a narrowing pulse pressureCevap
  2. A urine output of 15 mL collected over the first hour post-procedureCevap
  3. C
    An arterial blood gas (ABG) result showing a pH of 7.38, PaCO2 of 42 mmHg, and HCO3 of 24 mEq/L
  4. D
    The primary nurse assisting the client into a high-Fowler's position
  5. A rigid, board-like abdomen with generalized guarding upon palpationCevap

Cevap

The assessment findings requiring immediate follow-up are the heart rate of 118 beats per minute with a narrowing pulse pressure, the urine output of 15 mL over the first hour, and the rigid, board-like abdomen.
Following a large-volume paracentesis, clients are at extremely high risk for Post-Paracentesis Circulatory Dysfunction (PPCD) and hypovolemic shock due to rapid fluid shifts. Tachycardia combined with a narrowing pulse pressure and severe oliguria (15 mL/hr) are early, critical indicators of this life-threatening shock state. Additionally, a rigid, board-like abdomen with guarding is a definitive sign of peritonitis resulting from an accidental bowel perforation. All three of these findings indicate impending physiological decompensation and require immediate medical intervention.

Adım Adım Çözüm

1
Analyze the specific physiological risks associated with a large-volume paracentesis.
The primary risks include profound intravascular fluid shifts leading to hypovolemic shock (Post-Paracentesis Circulatory Dysfunction) and organ damage such as accidental bowel puncture.
Rapid removal of ascitic fluid causes sudden splanchnic vasodilation and a significant decrease in effective arterial blood volume.
2
Evaluate the clinical findings for indicators of systemic shock or hypoperfusion.
A heart rate of 118 bpm coupled with a narrowing pulse pressure, along with an hourly urine output of only 15 mL, are critical indicators of decreased tissue perfusion.
Tachycardia and a narrowed pulse pressure are early compensatory mechanisms to maintain cardiac output; oliguria confirms inadequate renal blood flow.
3
Evaluate the clinical findings for signs of procedural trauma.
A rigid, board-like abdomen with guarding is an acute emergency finding.
This physical presentation is the cardinal sign of peritonitis, strongly suggesting an accidental bowel perforation occurred during the procedure.
4
Assess the remaining routine clinical data and nursing actions for appropriateness.
The ABG values are within expected normal limits, and placing the client in a high-Fowler's position is a therapeutically correct intervention.
Expected or normal findings and correct interventions do not require immediate correction or follow-up by the charge nurse.

Anahtar Kavram

Recognizing the manifestations of Post-Paracentesis Circulatory Dysfunction (PPCD) and procedural complications (peritonitis) to mitigate risk.
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Konular

Reduction of Risk Potential

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