Walkthrough: Reduction of Risk Potential Q12 – NCLEX-RN®

00:00 A client diagnosed with alcoholic cirrhosis and ascites undergoes a paracentesis.

00:07 Following the procedure, which assessment finding is a priority for followup? Okay, 2 sentences, but a lot of work to be done here before we look at the answer choices. So I now have a client diagnosed with 2 things, alcoholic cirrhosis and cirrhosis means liver damage. Right? And this liver damage was caused by excessive alcohol for what their body could handle. So this is liver damage caused by excessive alcohol compared to what their body could handle. Why am I hanging on this point? Because alcoholic is a descriptor word. In this case, it may or may not play a big deal, but you always want to take a look at those descriptor words because they can change that. Right? If I'm talking about hepatitis, toxic hepatitis would be inflammation of my liver or something going on in my liver caused by something I ingested. That's very different than viral hepatitis because that is easily spread to another person. But toxic hepatitis is not spread to another person. It's a problem that I ingested something and that damaged my liver. So, descriptor words matter. So, somebody with alcoholic cirrhosis and ascites. So I know that that is, they've got all this excess fluid in their belly and we do a whole video series on why somebody with liver damage ends up with ascites. Now, they undergo a procedure. It's called a paracentesis, paracentesis. Anytime this is done, a needle is actually placed through the abdominal wall and fluid is drawn out. So, that's what a paracentesis is, we're looking to pull excess fluid off this patient's abdominal wall because they have this build-up of fluid because their liver is not doing well. So, following the procedure, which is a paracentesis, which assessment finding is a priority for follow-up? Well, when we see that, we're always thinking "I'm going to look for the top priority" meaning I need to eliminate the 3 other options that are either not connected to this procedure of paracentesis or they're not as severe as the final correct answer. So you've got 4 options, write down the numbers 1, 2, 3, and 4, no words, just write the numbers down on your scratch paper. As you're going through the question, ask would this be a priority after a paracentesis, yes or no? Would this be a priority after a paracentesis, yes or no? And don't forget why for every evaluation. Then, cross through the answer choices, make sure you feel confident about your answer but the one that's remaining, say why you think it's the right answer then restart the video and come back we'll go for the walk through together. Okay, welcome back. Do you commit to your answer? Let's take a look.

03:09 Now we have just 4 assessments. Right? So I look at the assessments, hypotension, I don't like that. That's going to be a perfusion problem but I'm going to have to see if it's at all attached or connected to a paracentesis. Elevated SGOT or AST. Well, that's a sign of liver damage, that's not good. Some fluid leakage from the puncture site, I'm not comfortable with that, and bacterial cells and a urinalysis. Now by the time I move through all those answer choices, if I'm not being really diligent and intentional about saying "Would this be a priority after a paracentesis?" I could end up getting tripped up by a silly answer like number 4 because there is no connection to bacterial cells and a urinalysis and a paracentesis but sometimes when I get stressed and you're going through questions and things are going on in your mind your mind is kind of worrying, you're going to think like "Oh, hey bacterial cells and urinalysis that's a bad thing. I think we should follow up on that." But it doesn't have anything to do with the topic of the question. And that's where students can struggle. So, number 4, you're out. Right? You're not a priority for followup for someone having a paracentesis. Now, I don't like fluid leaking from the puncture site. That doesn't seem like a good idea. I don't want their liver to be damaged but I also have hypotension. All 3 of these answer choices are they connected to paracentesis? 3 yes, 2 could be, 1. 1, what would hypotension have to do with paracentesis? When we picture what that is, you're pulling fluid volume off. So anytime I change the status of some of these fluid volume status in their body, you are at a risk for dropping their blood pressure. Okay, so that does have a connection. So anytime you do an esis, a paracentesis, a diuresis, if you are doing anything that causes fluid volume shifting and sticking a needle in somebody's belly and pulling out fluid you are shifting fluid outside their body, that's going to cause a change inside their body too. Anytime you have a fluid volume status change or shifting, you're risking what we call officially circulatory collapse.

05:31 What that means is their blood pressure is going to tank. Because this is really complicated in here, keeping all your squishiness in the right spots and out of the others. So hypotension, I'm leaving in. Now, I'm going to compare it to the other two. Elevated SGOT or AST. Well, they already told me that's an elevated liver gig, that's liver test and somebody with cirrhosis is already going to have elevated SGOT especially if it's bad enough that you got the big barrel belly full of acidic fluids. So, 2 is not a higher priority than number 1. Number 3, some fluid leakage from the puncture site. You know, my brain goes to what I like a fountain? like it's all these stuff just like phew. No, don't make a movie, that's being Spielberg. Don't make a movie. So, number 3 is not a bigger risk than number 1 because it just says some fluid is leaking from the puncture site. Am I going to keep an eye on it? Absolutely. If I've got a little bit, not a big deal. I'm going to watch that dressing like a hulk because I'm the nurse but I am watching if this patient has low blood pressure. In fact, this is what always made me nervous when I help with the paracentesis or a thoracentesis in the lungs, but I know their blood pressure can drop. The more fluid they pull off, the more sensitive the patient is, the bigger the drop in blood pressure can be. So that's why whoever is doing the procedure, whatever physician or practitioner is doing that procedure, we'll make some very calculated decisions on the patient's hemodynamic stability, how much fluid they can take off and still maintain that stability. The reason we do this kind of paracentesis is because with all these fluid in their abdomen, their lungs are like up here, "I can't breathe" because it's pushing on their lungs. So, just making that internal cavity that much less. So that's why we do it is for patient comfort. They'll also run cultures and things on it, but anytime you cause a fluid volume shift like guys, this is notebook material, just needs to go in your notebook. Any esis, diuresis, paracentesis, thoracentesis, anything where you're causing fluid volume shifting in someone's body puts them at a risk for that circulatory system to tank or hypotension. Now, we've got a perfusion problem. So that's what you want to take with you to other questions. If you didn't know what SGOT was, make sure you get that in your notes. Know that we don't want fluid leakage but you can see when you compare it to low blood pressure, number 1 is a bigger deal and it has a connection, a very clear connection to paracentesis. Number 4, yeah we don't like that but it does not have any connection to paracentesis. So good work, spend the time, reflect to see what needs to go down in your notebook, what notes would you learn about yourself on this question. Maybe there's a strategy you need to adjust to remember .Why do you think you got it right? Why do you think you got it wrong? What do you want to do differently on your next question? That's the heavy lifting.

08:38 Keep going, you can do this, and join us for more questions.