The unlicensed assistive personnel (UAP) assists a client with cirrhosis who underwent paracentesis 4 hours ago. The UAP reports to the nurse that the client was lightheaded and unsteady while ambulating to the chair. Which action should the nurse implement first?

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Paracentesis is a procedure that involves removal of excess fluid from the peritoneal cavity (ascites) and is performed to relieve dyspnea and discomfort related to increased intra-abdominal pressure and fluid volume. Hypovolemia is an associated complication related to intravascular fluid shifts that occur during and post-procedure and also to high volume peritoneal fluid removal (>5 L). The nurse should first validate the presence of light-headedness and unsteady gait, monitor vital signs, and assess for manifestations of hypovolemia (eg, orthostatic hypotension, tachycardia, reduced pulse volume, decreased urine output), as decreased circulating volume can lead to hemodynamic instability. (Option A) Post-paracentesis vital signs are frequently monitored for the first 4 hours to assess for complications (eg, hypotension, bleeding). The nurse can ask the UAP to take another set of vital signs, but this should not be the nurse's first intervention. (Option C) Diuretics (eg, spironolactone, furosemide) are prescribed for clients with ascites. If the client is hypotensive or hypovolemic, the nurse can hold the prescribed diuretics, but this should not be the nurse's first intervention. (Option D) The nurse can instruct the UAP to assist the client back to bed if this is an appropriate action after assessing the client, but this should not be the nurse's first intervention. Educational objective: A client who is experiencing lightheadedness and unsteady gait following paracentesis requires immediate assessment because these manifestations can signal hypovolemia with hypotension, which can lead to hemodynamic instability and hypovolemic shock.

The Unlicensed Assistive Personnel (UAP) Assists a Client with Cirrhosis