To evaluate a client’s condition following cardiac catheterization, the nurse will palpate the pulse:
A. In all extremities
B. At the insertion site
C. Distal to the catheter insertion
D. Above the catheter insertion
Correct Answer: C. Distal to the catheter insertion
Palpating pulses distal to the insertion site is important to evaluate for thrombophlebitis and vessel occlusion. They should be bilateral and strong. Assess limb for color, warmth, CRT, pulse strength, sensation, movement and pain. The affected limb will appear pale and cool and have diminished or absent pulses distal to the insertion site; additionally there may be decreased sensation and delayed CRT due to lack of supply of arterial blood. The nurse may notice a limb with decreased perfusion; assess pressure dressing to ensure it is not too tight. For accurate assessment of the pulse, mark the pulse position with a pen. A Doppler ultrasound can be utilized if a pulse is not palpable.
Option A: Assess and record patient observations. These should include assessment of behavior (alertness, lethargy, irritability), limb strength and range of motion, facial symmetry, Glasgow Coma Score. Maintain continuous cardiorespiratory monitoring to measure vital signs: HR, RR, BP, SpO2.
Option B: Assess the puncture site 30 minutes for 4 hours then hourly until ambulation. Reassess site after the first ambulation and then a minimum of 4 hourly prior to discharge. The puncture site assessment commences from the time the patient enters the PACU, not when they are transferred to the inpatient unit.
Option D: Neurological observations should be performed each shift or more frequently if complicated with a thrombus post-cardiac catheter. The risk of arterial ischemic strokes increases in a patient complicated with an intracardiac thrombus in the left atrium, and/or thrombus in the superior or inferior vena cava in those with single ventricle physiology or right-to-left shunt.
No comments:
Post a Comment