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Zorluk: ZorReduction of Risk Potential

During the initial recovery period following a percutaneous coronary intervention via the right femoral approach, a client reports a new, deep ache in the right lower back. Vital sign trending over the past 30 minutes shows the heart rate increasing from 82 to 114 bpm and the blood pressure decreasing from 128/74 to 104/58 mm Hg. Which action is the priority?

  1. Assess the right groin and retroperitoneal area for firmness, swelling, and ecchymosisCevap
  2. B
    Assist the client into a side-lying position to alleviate pressure on the lower back
  3. C
    Administer the prescribed as-needed intravenous analgesic for the reported discomfort
  4. D
    Document the findings and maintain continuous vital sign monitoring every 15 minutes

Cevap

The priority action is to assess the right groin and retroperitoneal area for firmness, swelling, and ecchymosis.
The correct action directly addresses the most critical risk. The client's symptoms (new back pain, tachycardia, and decreasing blood pressure) strongly suggest a retroperitoneal hemorrhage. Inspecting the groin and flank for ecchymosis (Grey Turner's sign) and swelling is the immediate priority assessment to validate this life-threatening complication so rapid intervention can be initiated.

Adım Adım Çözüm

1
Analyze the clinical cues provided in the scenario.
The client has new lower back pain, tachycardia (HR 114), and falling blood pressure (BP 104/58) following a right femoral artery procedure.
Identifying abnormal trends is the first step in recognizing post-procedure complications.
2
Correlate the symptoms with potential physiological complications of a femoral access procedure.
The combination of flank/back pain and signs of hypovolemia strongly indicates retroperitoneal bleeding, a life-threatening complication of femoral arterial access.
Blood leaking from the femoral artery can track backward into the retroperitoneal space, causing severe pain and subtle early signs of shock.
3
Determine the priority nursing action using the nursing process.
The nurse must immediately assess the groin and flank for physical signs of bleeding (ecchymosis, swelling, firmness) to confirm the suspicion before escalating care.
Targeted physical assessment provides necessary data to report to the healthcare provider for immediate medical intervention.

Anahtar Kavram

Recognition and mitigation of retroperitoneal hemorrhage following femoral artery access.
Tahmini Süre:1m 15s
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Konular

Reduction of Risk Potential

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