The nurse is caring for a patient who has a catheter in the right radial artery for invasive arterial blood pressure monitoring after abdominal aortic aneurysm surgery. Which observation requires emergency intervention?Arterial pressure bag is inflated to 250 mm Hg.Calculated mean arterial pressure is 74 mm Hg.Patient’s head of bed elevation is at 30 degrees.Capillary refill time in the right hand is 5 seconds.
Cap refill in right hand is 5 secondsNeurovascular status distal to the arterial insertion site is monitored hourly. If arterial flow is compromised, the limb will be cool and pale, with capillary refill time longer than 3 seconds. Symptoms of neurologic impairment include paresthesia, pain, or paralysis. Neurovascular impairment can result in loss of a limb and is an emergency. The pressure bag should be inflated to 300 mm Hg. Normal range for mean arterial pressure is 70 to 105 mm Hg. The backrest elevation may be up to 45 degrees unless the patient has orthostatic changes.
Capillary refill time in the right hand is 5 seconds. This observation requires emergency intervention. Capillary refill time is the time taken for blood to return to the tissues after pressure is applied to a small area. A normal capillary refill time is less than 2 seconds. A capillary refill time of greater than 2 seconds indicates poor circulation to the area. In this case, the capillary refill time in the right hand is 5 seconds, which is a sign of poor circulation to the hand. This could be due to arterial occlusion or other emergent issues, such as bleeding or clot formation. It is important to notify the physician immediately and discontinue the arterial line in the right radial artery to prevent any further complications.
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