The nurse has just received report. Which client should the nurse assess first?

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Post-procedure care of a client who has undergone heart catheterization should focus on evaluating hemodynamics - blood pressure, heart rate, strength of the distal pulses, color, and temperature of extremities. The client should be also assessed several times per hour for active bleeding, hematoma, or pseudoaneurysm formation at the incision. The first hour after cardiac catheterization requires assessment every 15 minutes. Any report of back or flank pain should be assessed for possible retroperitoneal bleeding as back pain, tachycardia, and hypotension may be the only indication of internal bleeding. More than a liter of blood can pool behind the peritoneum in the pelvis undetected, and it may take up to 12 hours before a significant drop in hematocrit can be measured. Internal bleeding after cardiac catheterization is particularly dangerous due to frequent use of anticoagulant prescriptions in these clients. (Option B) A heparin infusion is used for a client with DVT. An aPTT of 60 indicates a therapeutic value. The therapeutic range for a client on anticoagulation is usually 46-70 seconds (1½ -2 times the normal value). (Option C) This client should be evaluated hourly for any change in neurological status. However, because the highest possible score on the Glasgow Coma Scale is 15 for a fully alert person, a client with a score of 14 is not in need of urgent reassessment. (Option D) The report of incisional pain on postoperative day 2 would take second priority for further assessment, but evaluating a client with possible internal bleeding takes priority. Educational objective: Clients with any indication of compromised airway, breathing, or circulation always take priority. Signs of retroperitoneal bleeding are subtle and the onset of back pain or hypotension after angiography always requires further assessment for internal bleeding.

The Nurse Has Just Received Report