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Zorluk: ZorReduction of Risk Potential

A nurse is assessing a client who underwent a percutaneous coronary intervention (PCI) via the right femoral artery 2 hours ago. The client suddenly reports a warm, wet sensation in their right groin. The nurse immediately dons clean gloves and observes active arterial bleeding and a rapidly expanding hematoma. Place the following nursing interventions in the correct priority sequence to manage this complication.

  1. 1Apply firm, direct manual pressure approximately 2.5 cm (1 inch) above the femoral skin puncture site.
  2. 2Activate the emergency call system in the room to summon immediate assistance.
  3. 3Evaluate the client's blood pressure and heart rate to detect signs of hemodynamic instability.
  4. 4Assess the color, temperature, and pedal pulses of the affected lower extremity.
  5. 5Apply a mechanical compression device or pressure dressing after active bleeding is controlled.

Cevap

The correct sequence is: 1) Apply firm manual pressure above the site, 2) Activate the emergency call system, 3) Evaluate blood pressure and heart rate, 4) Assess the affected lower extremity, and 5) Apply a mechanical compression device.
In the event of an arterial hemorrhage post-cardiac catheterization, the nurse's first priority is to stop the bleeding by applying direct pressure slightly above the skin puncture site, following the anatomical track of the needle to the actual arteriotomy. Once pressure is applied, the nurse must immediately summon help without leaving the client. Next, systemic perfusion (vital signs) must be assessed to rule out life-threatening hypovolemic shock, followed by an assessment of the affected limb for localized ischemia. Finally, a definitive pressure dressing or mechanical device is applied once hemostasis is achieved.

Adım Adım Çözüm

1
Identify the most immediate life-threatening issue.
The client is experiencing an active arterial hemorrhage from the femoral artery.
According to the ABCs (Airway, Breathing, Circulation) framework, severe arterial bleeding compromises circulation and requires immediate mechanical intervention (pressure) to prevent exsanguination.
2
Determine the next crucial action after controlling the bleeding.
The nurse must activate the emergency call system.
The nurse cannot safely leave the bleeding client to get supplies or call the provider, so help must be summoned directly to the bedside.
3
Prioritize systemic assessment over localized assessment.
Evaluate systemic vital signs, including blood pressure and heart rate.
Systemic perfusion takes priority over limb perfusion. The nurse must determine if the blood loss has caused systemic hemodynamic instability, such as hypovolemic shock.
4
Assess localized complications.
Evaluate the distal pulses, color, and temperature of the affected leg.
After systemic stability is addressed, the nurse must ensure that the hematoma or the applied manual pressure has not completely compromised arterial blood flow to the foot, which could cause tissue ischemia.
5
Identify the final resolution step.
Apply a mechanical compression device or pressure dressing.
This step replaces manual pressure only after hemostasis is successfully achieved and the client is hemodynamically stable.

Anahtar Kavram

Prioritization of care for post-cardiac catheterization complications
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Konular

Reduction of Risk Potential

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