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Difficulty: HardPhysiological Adaptation

During hourly rounds, the practical nurse (PN) evaluates a 70-year-old client who is receiving a continuous intravenous heparin infusion for a pulmonary embolism. The client is suddenly shifting constantly in bed, appears slightly diaphoretic, and states, "I just feel like something terrible is going to happen." Current vital signs reveal a heart rate of 112 beats/min and a blood pressure of 106/68 mm Hg. The client's baseline vital signs from the previous shift were a heart rate of 78 beats/min and a blood pressure of 144/82 mm Hg. Which action should the PN take first?

  1. A
    Wait one hour and recheck the vital signs since the current blood pressure remains above 100 mm Hg systolic.
  2. B
    Reassure the client that feelings of anxiety are common during a hospital stay and dim the room lights.
  3. C
    Ask the client to rate any current discomfort and prepare to administer a prescribed PRN analgesic.
  4. Notify the registered nurse immediately to report the sudden behavioral and hemodynamic changes.Answer

Answer

The priority action is to immediately notify the registered nurse to report the sudden behavioral and hemodynamic changes.
The client is exhibiting classic early signs of shock or internal hemorrhage (tachycardia, relative hypotension, diaphoresis, and a sense of impending doom). Given the continuous heparin infusion, the risk of bleeding is high. The PN must immediately escalate these life-threatening physiological changes to the registered nurse for rapid, collaborative intervention.

Step-by-Step Solution

1
Analyze the client's current assessment data compared to the baseline.
The client has a significantly elevated heart rate (from 78 to 112 beats/min) and a significant drop in blood pressure (from 144/82 to 106/68 mm Hg) alongside new diaphoresis and restlessness.
Comparing current data to baseline is essential to identify physiological deterioration, rather than relying solely on absolute standard normal ranges.
2
Correlate the physical findings with the client's current treatments and risks.
The continuous heparin infusion places the client at a high risk for internal hemorrhage. The vital sign trends and the feeling of "impending doom" are classic indicators of early hypovolemic shock or further pulmonary compromise.
Connecting the pharmacological risk factors to the acute presentation helps determine the urgency of the situation.
3
Determine the appropriate action within the practical nurse's scope of practice.
The PN must recognize this acute physiological deterioration and immediately escalate the situation to the registered nurse (RN) or provider.
Rapid escalation is necessary to initiate prompt RN-level assessment and potential medical interventions for a hemodynamically unstable client.

Key Concept

Early Recognition of Shock and Physiological Adaptation
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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