Question

A client with hepatitis \(\mathrm{C}\) has just arrived after a liver biopsy. Which action does the nurse perform first? A. Assess preprocedure coagulation studies B. Provide pressure at the site by positioning the client on the right side C. Do a detailed chest and abdominal assessment D. Perform discharge teaching of allowed activities

Short answer

Answer: B. Provide pressure at the site by positioning the client on the right side.

Step-by-step solution

Identify the primary concern for the client after a liver biopsy.

In this case, the primary concern after a liver biopsy is ensuring adequate clotting and preventing bleeding. This will guide the decision on which nursing action to take first.

Evaluate each answer choice.

Analyze the answer choices in terms of their relevance to the primary concern. A. Assess preprocedure coagulation studies: It's important, but this action would have been performed before the biopsy to ensure the safety of the procedure. B. Provide pressure at the site by positioning the client on the right side: Placing the patient on the right side applies pressure to the biopsy site, promoting clotting and minimizing bleeding. C. Do a detailed chest and abdominal assessment: While essential, this assessment can be performed after addressing the primary concern of preventing bleeding. D. Perform discharge teaching of allowed activities: Addressing post-operative care is important, but not the immediate priority following the procedure.

Choose the correct answer based on evaluation.

Based on the primary concern for the client after a liver biopsy and the evaluation of each answer choice, the correct answer is: B. Provide pressure at the site by positioning the client on the right side.

Key concepts

Nursing Actions Post-Biopsy

After a liver biopsy procedure—like the case with a client having hepatitis C—nursing actions post-biopsy are critical in ensuring patient safety and recovery. The immediate priority is preventing bleeding and facilitating clotting at the biopsy site. It is important for the nurse to monitor vital signs closely, including blood pressure and heart rate, as these can indicate internal bleeding.

Nurses should also keep a close eye on the site of the biopsy for any signs of bleeding or hematoma formation. Patients should be informed about the importance of staying still and avoiding sudden movements that could disrupt clot formation. Education on the signs of potential complications, such as severe abdominal pain, dizziness, or changes in coloration around the biopsy site, is also necessary as part of the post-procedure monitoring.

In addition to these actions, it's crucial to maintain a record of any pain the patient experiences and administer pain management as prescribed. Regularly updating the patient's electronic health records ensures that any changes in their condition are documented promptly for timely intervention, if needed.

Preventing Bleeding After Biopsy

To prevent bleeding after a liver biopsy, several strategies are employed. Firstly, positioning the patient correctly—on the right side—creates pressure on the biopsy site to aid in clot formation and minimize the risk of bleeding. This is the first line of defense against post-biopsy bleeding.

Additionally, the use of a pressure dressing over the biopsy site might be recommended to provide continued, gentle pressure, helping to both secure the bandage in place and assist in hemostasis. It is also essential to limit the patient's physical activity post-biopsy; they should be instructed to avoid lifting heavy objects or engaging in strenuous exercise for a period as advised by the physician.

Nurses should keep in mind that certain medications, such as anticoagulants and non-steroidal anti-inflammatory drugs (NSAIDs), can increase bleeding risk, and therefore, a thorough review of the patient's medication history is a crucial preventive measure against post-biopsy bleeding complications.

Patient Positioning for Clotting

Proper patient positioning following a liver biopsy is essential for promoting clotting and reducing the risk of hemorrhage. The recommended position is to have the patient lie down on their right side—also known as the right lateral decubitus position—which exerts pressure on the liver area, helping to minimize the space where bleeding can occur and promoting the formation of a stable clot over the biopsy site.

This position should be maintained for several hours post-biopsy as per the procedural protocol or healthcare provider's instructions. Patients need to be aware of the importance of maintaining this position and should be assisted when necessary to ensure they remain safely on their right side. It is also vital to reposition them carefully and periodically to prevent pressure ulcers or discomfort, without jeopardizing the stability of the pressure applied to the biopsy site.

Throughout this period, ongoing assessment is imperative, and nursing staff should regularly check the patient's condition, monitor for any signs of bleeding, and provide reassurance and comfort. Clear communication regarding the importance of these measures is key for patient compliance and successful post-biopsy recovery.