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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is collecting data on an 82-year-old client who is receiving intravenous antibiotics for severe pyelonephritis. Which of the following assessment findings should the PN identify as early indicators of systemic decompensation and potential septic shock that require immediate notification to the registered nurse (RN)? Select all that apply.

  1. Heart rate of 118 beats per minuteAnswer
  2. New-onset confusion and restlessnessAnswer
  3. Respiratory rate of 28 breaths per minuteAnswer
  4. D
    Cloudy, foul-smelling urine in the collection bag
  5. E
    Client report of dull flank pain rated as 3 on a 0-to-10 scale
  6. F
    Blood pressure of 122/78 mm Hg

Answer

The findings that indicate early systemic decompensation and require immediate RN notification are a heart rate of 118 beats per minute, new-onset confusion and restlessness, and a respiratory rate of 28 breaths per minute.
In the early (compensatory) stages of septic shock and systemic inflammatory response syndrome (SIRS), the body attempts to maintain cardiac output and oxygen delivery to tissues. This physiological adaptation results in an increased heart rate (tachycardia) and an increased respiratory rate (tachypnea). Additionally, older adults are highly sensitive to slight decreases in cerebral oxygenation and perfusion, making new-onset confusion or restlessness one of the earliest and most reliable indicators of systemic deterioration. These findings require immediate intervention to prevent irreversible organ damage.

Step-by-Step Solution

1
Identify the client's current diagnosis and primary risks.
The client has severe pyelonephritis (a kidney infection), which places them at high risk for systemic inflammatory response syndrome (SIRS) and septic shock.
Understanding the clinical context helps distinguish between expected disease symptoms and life-threatening complications.
2
Evaluate the assessment findings to distinguish between localized expected symptoms and systemic emergency signs.
Flank pain and cloudy urine are expected local signs. Tachycardia, tachypnea, and altered mental status are abnormal systemic signs.
The PN must differentiate baseline or expected disease manifestations from acute changes that indicate deterioration.
3
Prioritize the findings based on Airway, Breathing, and Circulation (ABC) principles.
The elevated heart rate, elevated respiratory rate, and new-onset confusion represent early circulatory and respiratory compromise (shock) and must be reported immediately.
Systemic shock is a life-threatening emergency that takes precedence over expected localized infection signs or routine pain management.

Key Concept

Early Recognition of Septic Shock and SIRS
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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