A patient returns to the ICU after a femorotibial bypass graft of the left leg. Identify the primary focus of nursing care immediately in the postprocedural assessment period

a. Prevention of skin breakdown
b. Hourly intake and urinary output
c. Monitor for ST segment changes
d. Frequent pulse checks to the affected limb


D
The primary focus of nursing care in the immediate postprocedural period is assessment of the adequacy of perfusion to the affected limb and identification of complications. Pulse checks are performed frequently, and the physician is notified of any decrease in the strength of the Doppler signal. Because distal perfusion is compromised in this patient population, nursing measures to prevent skin breakdown are implemented. If the repair was performed above the renal arteries, kidney function may be impaired as a result of interruption of renal blood flow during the procedure. Urine output is therefore assessed hourly and supported with fluids and diuretics as needed. Because patients with peripheral vascular disease are at high risk for cardiac events, ST segment monitoring is performed to detect episodes of myocardial ischemia throughout the perioperative period.

Nursing

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