The nurse in the cardiac recovery unit is caring for a 62-year-old male client.
1000:Femoral cardiac catheterization finished 1 hour ago. The right femoral sheath has been removed. The dressing was dry when the client arrived in recovery. Bright red blood now spreads beyond the dressing and pools on the sheet. Client reports dizziness while lying in bed. A nurse has begun firm manual pressure, but bleeding continues. Both feet remain warm with palpable pedal pulses. Client denies chest discomfort, abdominal pain or flank pain. The cardiac monitor shows sinus tachycardia. A second nurse is at the bedside. The primary health care provider (PHCP) is on the unit.
The nurse is reviewing the client's assessment data to prepare the client's plan of care.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Action to TakeAction to Take
Condition Most Likely ExperiencingParameter to MonitorParameter to Monitor
Actions to Take
Offer the client oral fluids.
Maintain firm pressure over the site.
Assist the client to a seated position.
Notify the PHCP of the ongoing bleeding.
Change the dressing and reassess in 15 minutes.
Potential Conditions
vasovagal reaction
access-site hemorrhage
acute coronary ischemia
retroperitoneal bleeding
Parameters to Monitor
blood pressure
serum creatinine
ST-segment changes
access-site bleeding
abdominal or flank pain