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Zorluk: ZorReduction of Risk Potential

A 68-year-old client is transferred to the progressive care unit following a percutaneous coronary intervention (PCI) utilizing a right femoral artery approach. The client has a history of hypertension and osteoarthritis. Three hours post-procedure, the nurse performs a scheduled assessment and notes the following:
- Blood pressure is 104/62 mm Hg, down from a pre-procedure baseline of 142/86 mm Hg.
- Heart rate has increased to 112 bpm from 74 bpm.
- The right groin dressing remains dry and intact without visible hematoma.
- Bilateral pedal pulses are equal and easily palpable.
- The client reports, "My lower back is aching severely, but it is probably just my arthritis acting up from this firm mattress."

Which action should the nurse take first to reduce the client's risk for physiological decompensation?

  1. Gently roll the client to one side to inspect the flank and posterior lower back for ecchymosisCevap
  2. B
    Elevate the head of the bed to 45 degrees and place a supportive pillow under the lower spine
  3. C
    Administer the prescribed as-needed oral analgesic to treat the musculoskeletal discomfort
  4. D
    Obtain a Doppler ultrasound to verify the presence and strength of the right dorsalis pedis pulse

Cevap

The nurse should gently roll the client to one side to inspect the flank and posterior lower back for ecchymosis.
The client is exhibiting subtle signs of a retroperitoneal hemorrhage, a critical complication of femoral artery access. Manifestations include back or flank pain, tachycardia, and hypotension. Because blood pools in the retroperitoneal space, the anterior groin dressing often remains dry and intact. The priority action is to visually assess the flank and lower back for ecchymosis (Grey Turner's sign) or swelling before notifying the healthcare provider.

Adım Adım Çözüm

1
Analyze the client's vital sign trends and symptom presentation.
The client exhibits a significantly lower blood pressure and higher heart rate than baseline, combined with new-onset severe back pain.
Identifying physiological deviations from baseline is necessary to recognize impending complications.
2
Correlate the clinical findings with the recent procedure (femoral PCI).
The femoral artery was accessed, creating a risk for hemorrhage. The combination of tachycardia, hypotension, and back pain suggests blood may be pooling internally in the retroperitoneal space.
Retroperitoneal hemorrhage is a life-threatening complication where bleeding occurs behind the peritoneum, often leaving the anterior groin dressing dry.
3
Determine the priority nursing intervention to confirm the suspected complication and reduce risk.
The nurse must inspect the posterior flank and lower back for physical signs of bleeding to validate the suspicion before urgently notifying the provider.
Thorough assessment of the suspected bleeding site directs immediate, life-saving interventions.

Anahtar Kavram

Recognition of subtle indicators of retroperitoneal hemorrhage following femoral artery access.
Tahmini Süre:1m 30s
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Konular

Reduction of Risk Potential

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