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Zorluk: ZorReduction of Risk Potential

A 68-year-old client with advanced cirrhosis and refractory ascites is receiving care on a medical-surgical unit. The client's baseline blood pressure is 132/82 mmHg. Three hours after a large-volume paracentesis during which 6 liters of ascitic fluid were removed, the client reports feeling slightly fatigued and nauseated. The client's current vital signs reveal a blood pressure of 102/64 mmHg, a heart rate of 110 beats/minute, a respiratory rate of 20 breaths/minute, and an oxygen saturation of 97% on room air. The abdominal dressing is dry and intact. What is the priority nursing action to mitigate the client's risk of further physiological decompensation?

  1. A
    Assist the client into a high-Fowler's position to promote optimal lung expansion and diaphragmatic excursion.
  2. B
    Delegate the collection of orthostatic vital signs to the unlicensed assistive personnel to closely monitor the blood pressure trend.
  3. Place the client in a supine position with the lower extremities elevated and anticipate a prescription for an intravenous colloid infusion.Cevap
  4. D
    Administer the scheduled daily dose of oral spironolactone to prevent the immediate reaccumulation of ascitic fluid.

Cevap

Place the client in a supine position with the lower extremities elevated and anticipate a prescription for an intravenous colloid infusion.
The client is experiencing early paracentesis-induced circulatory dysfunction (PICD), a form of hypovolemic shock triggered by rapid fluid shifts out of the vascular space following the removal of large volumes of ascitic fluid. Early indicators include tachycardia, a narrowing pulse pressure, and a drop from baseline blood pressure. Elevating the lower extremities while supine uses gravity to enhance venous return to the right atrium, immediately improving cardiac output. The nurse must also anticipate administering an intravenous colloid, such as albumin, which increases intravascular oncotic pressure and pulls fluid back into the circulatory system to sustain tissue perfusion.

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1
Analyze the client's vital sign trends in the context of the recent procedure.
The blood pressure has dropped from a baseline of 132/82 mmHg to 102/64 mmHg, and the heart rate is elevated at 110 beats/minute.
Identifying changes from baseline is critical for recognizing early physiological decompensation before overt shock occurs.
2
Correlate the assessment findings with the pathophysiological risks of a large-volume paracentesis.
The removal of 6 liters of fluid causes a sudden decrease in intra-abdominal pressure, leading to rapid splanchnic vasodilation and fluid shifts out of the intravascular space.
Understanding the mechanism of paracentesis-induced circulatory dysfunction (PICD) directs appropriate interventions.
3
Select the nursing intervention that directly mitigates the identified circulatory risk.
Positioning the client supine with elevated legs increases venous return, and colloid administration restores intravascular volume.
Risk reduction prioritizes immediate hemodynamic stabilization over routine medication administration or contraindicated positioning.

Anahtar Kavram

Paracentesis-Induced Circulatory Dysfunction (PICD)
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Konular

Reduction of Risk Potential

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