Question

A client is brought into the emergency department complaining of severe back pain. He is diaphoretic, pale, tachycardic, and has absent pedal pulses. Which is the immediate nursing intervention? A. Start an IV with a 16 gauge catheter B. Get a stat back x-ray C. Prepare the client for insertion of hemodynamic monitoring D. Get a 12 lead ECG

Short answer

Get a 12 lead ECG (D).

Step-by-step solution

Identify Symptoms and Conditions

The client is experiencing severe back pain, is diaphoretic (sweating heavily), pale, tachycardic (rapid heart rate), and has absent pedal pulses. These symptoms suggest a serious cardiovascular issue, possibly an aortic dissection or aneurysm.

Prioritize Interventions

Determine which interventions should be prioritized immediately based on the severity and implications of the symptoms. Immediate interventions are critical for conditions that threaten life or vital functions.

Evaluate Options

Consider each of the options provided: A. Starting an IV with a 16 gauge catheter B. Getting a stat back x-ray C. Preparing the client for insertion of hemodynamic monitoring D. Getting a 12 lead ECG Evaluate which action directly addresses the immediate need for cardiovascular assessment and stabilization.

Decision Rationale

Starting an IV (A) is necessary for fluid or medication administration but doesn’t offer immediate diagnostics for the heart. A back x-ray (B) is not immediately relevant to cardiac assessment. Hemodynamic monitoring preparation (C) is invasive and cannot be quickly started without prior assessment. A 12 lead ECG (D) provides immediate information on the cardiovascular status, which is critical.

Decide on Immediate Intervention

Based on the symptoms and the need for immediate cardiovascular assessment, the most appropriate intervention is to get a 12 lead ECG (option D). This will quickly provide data on heart function and guide further immediate treatment steps.

Key concepts

Cardiovascular Assessment

When a client presents with severe back pain, diaphoresis, pallor, tachycardia, and absent pedal pulses, it’s crucial to perform a thorough cardiovascular assessment. These symptoms can indicate a serious, potentially life-threatening condition like an aortic dissection or aneurysm.
Cardiovascular assessment involves evaluating the heart and blood vessels. This includes measuring heart rate and rhythm, checking blood pressure, and performing diagnostic tests.
One of the most immediate and vital tests is the 12 lead ECG.
This test helps to visualize the electrical activity of the heart and can reveal conditions such as myocardial infarction (heart attack) or arrhythmias.
An ECG is non-invasive and can provide rapid results, making it essential in the emergency department.
Prompt cardiovascular assessment is important to guide immediate treatment and improve patient outcomes.

Triage Prioritization

In an emergency setting, triage prioritization determines the order of treatment based on the severity of a patient's condition. When prioritizing care for a patient with possible cardiovascular issues, use the ABCs of triage: Airway, Breathing, and Circulation.
In this case, the patient's symptoms are directly related to circulation.
Immediate action is required to stabilize the patient. Tachycardia and absent pedal pulses indicate poor blood flow and possible cardiovascular compromise.
The primary goal is to prevent further deterioration and address life-threatening conditions first.
Hence, conducting a 12 lead ECG takes precedence over other interventions like starting an IV or getting a back x-ray.
This ensures that the patient's cardiovascular status is quickly assessed and managed, potentially saving their life.

Hemodynamic Monitoring

Hemodynamic monitoring involves measuring the pressures and flows within the cardiovascular system. This can provide detailed information about the heart's function and the blood vessels.
However, preparing a patient for hemodynamic monitoring is a complex and time-consuming process. Before starting, it's crucial to determine if such invasive monitoring is necessary.
In the initial assessment phase, less invasive methods like a 12 lead ECG can be more practical and provide critical information quickly.
After the initial assessment with the ECG, and based on its results, further hemodynamic monitoring may be warranted for continuous assessment and management.
In emergency cases, always prioritize rapid, informative, and less invasive diagnostics first to guide further interventions.

Nursing Decision-Making

Nursing decision-making is pivotal in emergency settings. Nurses must quickly analyze symptoms, prioritize interventions, and choose the most appropriate actions to stabilize the patient.
Effective decision-making involves critical thinking, clinical expertise, and adherence to established protocols.
In this scenario, recognizing that the patient’s symptoms indicate a serious cardiovascular issue guides the decision to promptly obtain a 12 lead ECG.
This choice is based on the need for rapid assessment and immediate information on the heart’s status.
Choosing the right intervention amongst various options demonstrates the nurse's ability to critically assess the situation and make informed decisions that enhance patient care and outcomes.