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The nurse is caring for a client with a liver failure who is having a percutaneous...

The nurse is caring for a client with a liver failure who is having a percutaneous liver biopsy. The assessment findings include a heart rate of 115 beats per minutes, a respiration of 24 breaths, and a blood pressure of 82/50 (60) mmHg. The client is lethargic and difficult to arouse. Which action should the nurse perform first?

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* Inform the physician and ask to stop the procedure and monitor the patient's abdominal girth to make sure if there is an abnormal increase in abdominal girth which indicate internal bleeding, and raise the foot end of the bed above heart level to decrease blood flow to the area.

* Other measures are administer vitamin K which helps for blood clotting immediately.

* Restrict the patient's movements on the bed.

••• Liver biopsy means removing a small amount of liver tissue to examine the liver cells for diagnostic purpose or to see the progress of treatment, it is usually done through a needle aspiration.

* The most common complication of liver biopsy is internal bleeding, changes in vital signs like increased heart rate (tachycardia ), hypotension (decreased blood pressure ) and increased respiratory rate (tachypnoea ) indicate bleeding., * Here the patient's heart rate is 115 beats per minute( tachycardia ) respiration is 24( tachypnoea )breaths and blood pressure 82/50mm of Hg( hypotension ) indicating less blood supply to vital organs and heart and lungs trying to improve oxyges and blood supply to organs.

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