A child in the intensive care unit had a pulmonary artery catheter inserted 2 hours ago. The child is increasingly restless. The child's vital sign trends show a slow increase in pulse rate
Which action by the nurse is the most appropriate based on the assessment findings?
A.
Check to ensure the connections are secure.
B.
Document the findings in the patient's chart.
C.
Increase the frequency of hemodynamic readings.
D.
Notify the health-care provider immediately.
ANS: D
A potential complication of inserting an invasive line for hemodynamic monitoring is vessel laceration, which can cause internal bleeding. Internal bleeding is often insidious, and changes will be noted over time, some of which can be subtle. The presence of increased agitation and pulse could indicate internal bleeding, and the nurse should notify the provider at once. The other actions are also appropriate, but do not take priority and can be done after notifying the provider.
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