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Soru

Zorluk: OrtaEstablishing Priorities

Upon returning from a break, a registered nurse receives status updates regarding four assigned clients. Which client must the nurse assess first?

  1. A client 4 hours post-percutaneous coronary intervention (PCI) via the right femoral artery who reports new, severe lower back pain.Cevap
  2. B
    A client admitted with acute pericarditis who reports sharp chest pain that worsens with deep inspiration and improves when leaning forward.
  3. C
    A client receiving a continuous heparin infusion for a deep vein thrombosis (DVT) who describes a continuous dull ache in the affected calf.
  4. D
    A client with an exacerbation of heart failure who has 2+ bilateral pitting pedal edema and a documented weight gain of 1 kg (2.2 lb) since yesterday.

Cevap

The client 4 hours post-percutaneous coronary intervention (PCI) reporting new, severe lower back pain.
Following a percutaneous coronary intervention (PCI) via a femoral approach, bleeding can occur internally into the retroperitoneal space. Because the bleeding is internal, there may be no visible blood at the access site. New, severe lower back pain or flank pain is often the earliest and only sign of retroperitoneal hemorrhage before overt signs of hypovolemic shock appear. This is a life-threatening circulatory emergency that takes highest priority.

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1
Analyze each client's presentation to determine if the findings are expected for their disease process or indicate an acute complication.
The findings for the clients with pericarditis, DVT, and heart failure are expected manifestations of their conditions. The back pain in the post-PCI client is unexpected.
Recognizing the difference between stable, expected disease manifestations and unstable, unexpected complications is the first step in prioritization.
2
Apply the Airway, Breathing, and Circulation (ABC) prioritization framework to the unexpected finding.
The post-PCI client is at high risk for retroperitoneal hemorrhage from the femoral artery access site, presenting as back pain. This represents a severe circulatory (C) compromise.
Clients with potential life-threatening airway, breathing, or circulatory emergencies must always be assessed and treated before clients with expected or stable chronic findings.

Anahtar Kavram

Prioritization: Recognizing Post-Procedural Hemorrhage
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Konular

Establishing Priorities

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