A nurse is assessing a client immediately following a cardiac catheterization.
The nurse should notify the provider for which of the following findings?
A.
Heart rate 90/min.
B.
Hematoma over the insertion site.
C.
Bounding pulses in the affected extremity.
D.
Report of discomfort at the insertion site continue.
The Correct answer and Explanation is:
Correct Answer: B. Hematoma over the insertion site.
Explanation:
Cardiac catheterization is a common diagnostic and interventional procedure used to evaluate or treat various heart conditions. During the procedure, a catheter is inserted into a large blood vessel (usually the femoral or radial artery) and guided to the heart. Post-procedure care is crucial to monitor for complications, including bleeding, hematoma formation, and vascular injury at the insertion site.
Why B is the Correct Answer: A hematoma over the insertion site is a concerning finding because it indicates bleeding into the tissue. This could signify that the artery has not sealed properly, leading to potential complications such as arterial occlusion, pseudoaneurysm, or significant blood loss. Hematomas can expand and lead to compression of the surrounding tissues, causing pain, ischemia, or even compartment syndrome in severe cases. Immediate intervention is necessary to prevent these complications, which may include applying pressure, administering medications, or surgical intervention.
Explanation of Incorrect Options:
- Option A: Heart rate 90/min: A heart rate of 90 beats per minute is within the normal range for an adult (60-100 beats per minute). Although tachycardia can be a concern, especially post-cardiac catheterization, a rate of 90/min is not immediately alarming and does not necessitate urgent notification unless it is accompanied by other symptoms like hypotension, chest pain, or arrhythmias.
- Option C: Bounding pulses in the affected extremity: Bounding pulses indicate increased blood flow to the area, which might be due to anxiety, pain, or the effects of medications used during the procedure. While this finding should be documented and monitored, it does not pose an immediate threat compared to a hematoma.
- Option D: Report of discomfort at the insertion site: Discomfort or mild pain at the insertion site is expected after the procedure and can be managed with analgesics. However, it is not as critical as the presence of a hematoma, which directly indicates a potential complication requiring urgent attention.
Conclusion: While all findings should be documented and monitored, a hematoma over the insertion site is the most critical finding, warranting immediate notification of the provider to prevent further complications.