Answer:
The priority area for the nurse's assessment after the placement of an implantable cardioverter defibrillator (ICD) is the incision site and surrounding area.
The nurse should carefully assess the incision site for signs of infection, hematoma, or excessive bleeding. The assessment includes:
Incision site: Inspect the incision site for any signs of redness, swelling, warmth, or discharge, which may indicate infection. Note the presence of sutures or staples and assess their integrity.
Drainage: Monitor for excessive drainage or bleeding from the incision site, as this could indicate a surgical complication or the need for further intervention.
Pain or tenderness: Assess the client's level of pain or discomfort at the incision site. The nurse should ask about any sharp or increasing pain, which may require further evaluation.
Hematoma or ecchymosis: Observe for the presence of any significant bruising or hematoma formation around the incision site, as this could indicate bleeding or complications.
In addition to the incision site, the nurse should also assess other relevant areas, including:
Vital signs: Monitor the client's blood pressure, heart rate, and rhythm to detect any irregularities or changes that may indicate complications or arrhythmias.
Electrocardiogram (ECG) monitoring: Continuously monitor the client's cardiac rhythm via telemetry or bedside ECG monitoring to detect any arrhythmias or abnormalities.
Pain assessment: Evaluate the client's level of pain or discomfort related to the procedure and administer appropriate pain management as needed.
Client education: Assess the client's understanding of the ICD, its function, and potential signs of complications. Provide education regarding ICD precautions, such as avoiding heavy lifting or contact sports, and signs of potential device malfunction.
While all areas of assessment are important, the immediate focus after ICD placement should be on ensuring the integrity of the incision site and identifying any signs of infection, bleeding, or hematoma formation. Prompt identification and intervention for any potential complications can help ensure the client's safety and optimal recovery.
Step-by-step explanation: