A patient is coming in ICU from the Nephrology department. On-duty nursing officer noticed that there is bleeding from the sheath site from the right hand. What is the first priority action of the on-duty officer?

1. A

   Immediately apply pressure with sterile gauze

2. B

   Inform the doctor

3. C

   Call to dialysis room to the dialysis nurse for help

4. D

   Immediately check blood pressure

Appeared in: JIPMER Nursing Officer - 2020

Explanation

• The immediate priority in any case of active hemorrhage is to stop the blood loss to prevent hypovolemic shock.
• Applying direct manual pressure is the most effective and immediate intervention to control external bleeding from a vascular access site, such as a sheath.
• This action directly addresses the 'C' (Circulation) component of the ABCs of emergency care, which takes precedence in this scenario.
• Controlling the source of the bleeding is the primary intervention; all other actions like notification and further assessment are secondary.

Why Other Options Were Wrong

• Option B: Informing the doctor is a necessary step, but it is not the first priority. Leaving the patient to make a call while they are actively bleeding would be a critical error, as significant blood loss can occur in a short time.
• Option C: While the dialysis nurse has specialized knowledge, the immediate responsibility lies with the nurse at the bedside. The primary nurse must initiate the life-saving intervention of applying pressure before seeking help from other departments.
• Option D: Checking blood pressure is an assessment, not an intervention. In a situation of active hemorrhage, the priority is to intervene to stop the problem (bleeding), not to measure its effects (potential hypotension).

Related Visual

Clinical Relevance

• Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Priority Nursing Actions in Hemorrhage in acute care settings.
• Nurses must be able to immediately recognize and act on life-threatening complications like hemorrhage. The ABC (Airway, Breathing, Circulation) framework is a fundamental tool for prioritizing actions in emergencies.
• Bleeding from a vascular access sheath, especially if it's an arterial sheath, can lead to rapid blood loss, hemodynamic instability, and hypovolemic shock if not controlled immediately.
• Patient Safety: The principle of 'intervene first, then assess and notify' is critical in active bleeding scenarios. The nurse's first duty is to the patient at the bedside.

How to Approach the Question

• First, identify the core problem presented in the clinical scenario. Here, the problem is active bleeding from a vascular access site.
• Next, recognize this as a life-threatening emergency. Active, uncontrolled bleeding is a critical 'Circulation' issue.
• Apply the ABC (Airway, Breathing, Circulation) principle to prioritize interventions. Since this is a circulation problem, an action that directly addresses it will be the highest priority.
• Evaluate the given options: Applying pressure is a direct intervention to stop the bleeding. Informing the doctor, calling for help, and checking BP are all important but are secondary actions (notification and assessment).
• Select the option that provides the most immediate and direct solution to the life-threatening problem. In this case, stopping the blood loss is paramount.

Concept Tested & Keywords

• Concept Tested: Priority Nursing Actions in Hemorrhage
• Stem keywords: ICU, Nephrology, bleeding, sheath site, first priority action
• Lead-in keywords: first priority action
• Clinical cues: Active bleeding from a vascular access site is a circulatory emergency.

Question ID

QLaPjQw0GjoN2W6zT7lbzS

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 1 p. 136-138

E6 Medicine Harrison 22e Part 2 p. 308-310

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 1 p. 128-130