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Zorluk: Çok zorBasic Care and Comfort

A 71-year-old client with a history of early-stage vascular dementia is 4 hours post-percutaneous coronary intervention (PCI) via the right femoral artery. The client suddenly becomes highly agitated, reports vague lower abdominal pressure, and repeatedly attempts to sit upright and pull at the groin dressing. The client has not voided since before the procedure. Which action should the nurse take to safely address the client's basic care and comfort needs?

  1. Maintain the head of the bed at 20 degrees, perform a bedside bladder ultrasound, and assist the client with using a fracture pan if retention is present.Cevap
  2. B
    Elevate the head of the bed to a high-Fowler's position to assist the client onto a standard bedpan, utilizing gravity to facilitate bladder emptying.
  3. C
    Apply soft bilateral wrist restraints immediately to prevent the client from dislodging the femoral dressing and causing a life-threatening hemorrhage.
  4. D
    Attribute the sudden agitation and inability to void to a transient worsening of the client's baseline cognitive impairment related to procedural stress.

Cevap

The safest action is to maintain the head of the bed at 20 degrees, perform a bedside bladder ultrasound, and assist the client with using a fracture pan if urinary retention is present.
The correct action synthesizes the need for elimination assistance with strict post-procedural safety. Agitation in this context points to a full bladder. A bedside ultrasound confirms retention, while keeping the head of the bed at 20 degrees and using a fracture pan prevents dangerous hip flexion, safeguarding the femoral arterial puncture site from rupture.

Adım Adım Çözüm

1
Analyze the clinical presentation and recognize the primary problem.
The client's sudden agitation, lower abdominal pressure, and lack of voiding for over 4 hours strongly indicate acute urinary retention, rather than just confusion.
Agitation in older adults or clients with cognitive impairment is frequently the first sign of a physiological unmet need, such as a full bladder.
2
Identify the contraindications based on the recent medical procedure.
The client is 4 hours post-PCI via the right femoral artery, meaning the right leg must remain straight and the head of the bed (HOB) must not be elevated above 30 degrees.
Excessive hip flexion (such as sitting upright) drastically increases the risk of arterial bleeding or retroperitoneal hematoma at the femoral puncture site.
3
Select the nursing intervention that safely resolves the basic care need (elimination) while adhering to positioning constraints.
Using a fracture pan with the HOB at 20 degrees allows for elimination without requiring the client to bend the affected hip or sit upright.
A fracture pan has a lower profile than a standard bedpan, allowing it to be slipped under the client with minimal lifting or rolling, protecting the femoral access site.

Anahtar Kavram

Basic Care Positioning and Elimination for Post-Procedural Clients
Tahmini Süre:1m 30s
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Konular

Basic Care and Comfort

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