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Zorluk: Çok zorReduction of Risk Potential

A 68-year-old client is 2 hours post-percutaneous coronary intervention (PCI) utilizing a right femoral artery approach. The arterial sheath was removed 45 minutes ago, and a mechanical compression device is currently in place. The client reports a new onset of vague right lower back and flank pain, accompanied by mild nausea. Over the past 45 minutes, the client's heart rate has progressively increased from 72 to 110 bpm, and the blood pressure has trended from 134/82 mm Hg down to 112/74 mm Hg. The right femoral insertion site is dry, intact, and free of any superficial bleeding or palpable hematoma. Which of the following actions is the priority for the nurse to perform to reduce the risk of severe physiological deterioration?

  1. A
    Elevate the head of the bed to 45 degrees to relieve the flank tension and apply a warm compress to the lower back.
  2. B
    Draw a STAT arterial blood gas sample to rule out metabolic acidosis as the etiology for the client's new-onset nausea and tachycardia.
  3. Maintain the client in a flat, supine position and immediately activate the rapid response team for suspected retroperitoneal hemorrhage.Cevap
  4. D
    Palpate the right flank deeply for a developing mass, followed by auscultating the abdomen to determine the cause of the nausea.

Cevap

Maintain the client in a flat, supine position and immediately activate the rapid response team for suspected retroperitoneal hemorrhage.
The correct answer accurately identifies a high-risk, life-threatening complication: retroperitoneal hemorrhage. Flank or back pain, accompanied by compensatory tachycardia, narrowing pulse pressure, and nausea following a femoral artery puncture, are classic early signs of internal bleeding. Because the blood tracks backward into the retroperitoneal space, the external insertion site often remains clean and dry without a palpable hematoma. The immediate priority is to maintain the client in a flat, supine position to prevent further mechanical stress on the arteriotomy and to activate the rapid response team to initiate aggressive volume resuscitation and advanced interventions.

Adım Adım Çözüm

1
Analyze the client's history and current clinical manifestations.
The client had a right femoral artery puncture. They now have new-onset right flank/back pain, increasing tachycardia, decreasing blood pressure, and nausea.
Identifying the constellation of symptoms following an invasive vascular procedure is critical for recognizing early complications.
2
Correlate the symptoms with potential post-procedural complications.
The symptoms strongly indicate internal bleeding into the retroperitoneal space. The external site is clear because the blood is tracking internally into the retroperitoneum.
Retroperitoneal hemorrhage is a life-threatening, hidden complication of femoral access that presents with flank pain and subtle signs of early hypovolemic shock before severe hypotension occurs.
3
Determine the safest, most immediate risk-reduction intervention.
The nurse must keep the client flat to minimize intra-abdominal pressure on the femoral puncture site and immediately activate emergency personnel.
Medical intervention (fluids, potential surgical coiling) is urgently required, and maintaining a flat position prevents exacerbation of the arterial bleed.

Anahtar Kavram

Early recognition and mitigation of retroperitoneal hemorrhage following femoral artery catheterization.
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Konular

Reduction of Risk Potential

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