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Zorluk: OrtaReduction of Risk Potential

A telemetry nurse is monitoring a 5858-year-old client who had a percutaneous coronary intervention (PCI) via the right femoral approach 33 hours ago. The client suddenly complains of a new, constant aching pain in the lower back. The latest vital signs indicate a blood pressure of 96/5496/54 mm Hg (baseline 128/76128/76 mm Hg), a heart rate of 115115 beats/min, and a respiratory rate of 2424 breaths/min. An arterial blood gas (ABG) sample drawn on room air shows a pH of 7.477.47, PaCO2PaCO_2 of 3030 mm Hg, PaO2PaO_2 of 9494 mm Hg, and HCO3−HCO_3^- of 2222 mEq/L. Which action should the nurse take first to mitigate the risk of further physiological deterioration?

  1. Notify the primary healthcare provider and anticipate an order for rapid intravenous fluid expansion.Cevap
  2. B
    Guide the client through breathing exercises to lower the respiratory rate and resolve the alkalosis.
  3. C
    Raise the head of the bed to 45 degrees to facilitate a visual inspection of the posterior flank.
  4. D
    Administer the prescribed as-needed analgesic to treat the back pain and recheck vital signs in one hour.

Cevap

The correct action is to notify the primary healthcare provider immediately and prepare for intravenous fluid resuscitation to manage the suspected retroperitoneal hemorrhage.
Post-PCI via the femoral approach, new-onset lower back or flank pain combined with hypotension and tachycardia are hallmark signs of a retroperitoneal hemorrhage. This is a severe, life-threatening bleeding complication. The absolute priority is to alert the healthcare provider and initiate rapid intravascular volume expansion to maintain perfusion.

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1
Analyze the client's symptoms and vital sign trends.
The client has new-onset lower back pain, a dropping blood pressure (96/5496/54 mm Hg), and a rising heart rate (115115 beats/min).
Identifying these acute changes is crucial for recognizing early signs of hypovolemic shock.
2
Correlate the physical findings with the recent procedure.
The client underwent a PCI via the femoral artery. Back pain combined with hemodynamic instability strongly indicates retroperitoneal bleeding.
The femoral artery can bleed posteriorly into the retroperitoneal cavity, masking external bleeding while causing significant internal blood loss and referred back pain.
3
Evaluate the ABG results in the clinical context.
The pH (7.477.47) and PaCO2PaCO_2 (3030 mm Hg) indicate an uncompensated respiratory alkalosis.
This acid-base imbalance is a secondary compensatory response driven by tachypnea due to shock, pain, and anxiety, not the primary physiological threat.
4
Determine the highest priority intervention to reduce risk.
The nurse must immediately notify the provider and prepare to restore intravascular volume.
Hemorrhagic shock is a medical emergency that requires rapid fluid resuscitation and potential surgical or endovascular intervention to prevent mortality.

Anahtar Kavram

Reduction of Risk Potential: Complications of Diagnostic Procedures (Retroperitoneal Hemorrhage)
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Konular

Reduction of Risk Potential

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