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Difficulty: HardPhysiological Adaptation

During a shift assessment at an extended care facility, a practical nurse observes a resident who has an indwelling urinary catheter. The nursing assistant reports that the resident, typically cooperative and calm, has suddenly become combative and is trying to pull out the catheter. The resident's current vital signs are heart rate 118 bpm, respirations 26 breaths/min, and blood pressure 92/54 mmHg. The resident's baseline blood pressure is 134/78 mmHg. Which action should the practical nurse take FIRST?

  1. Assess the resident's oxygen saturation and immediately alert the registered nurse.Answer
  2. B
    Reorient the resident to the room and apply soft wrist restraints to protect the catheter.
  3. C
    Review the resident's electronic medical record for recent white blood cell counts.
  4. D
    Instruct the nursing assistant to provide oral fluids and recheck the blood pressure in one hour.

Answer

The practical nurse should assess the resident's oxygen saturation and immediately alert the registered nurse.
The correct action directly addresses an immediate life-threatening physiological change. The sudden onset of combative behavior combined with significant tachycardia, tachypnea, and hypotension in a client with an indwelling urinary catheter strongly indicates urosepsis and impending shock. The practical nurse must prioritize the ABCs by obtaining essential oxygenation data and immediately escalating this critical situation to the registered nurse for rapid medical intervention.

Step-by-Step Solution

1
Analyze the resident's acute neurological and behavioral changes.
The resident has transitioned abruptly from calm to combative and confused.
Acute confusion in an older adult is often a primary indicator of a systemic physiological issue (such as infection or hypoxia), not a behavioral problem.
2
Evaluate the current vital signs against the resident's baseline.
The heart rate is significantly elevated (118 bpm), respiratory rate is rapid (26 breaths/min), and blood pressure has plummeted from 134/78 to 92/54 mmHg.
This triad of vital sign changes indicates hemodynamic instability and compensatory mechanisms for impending shock, likely urosepsis originating from the indwelling catheter.
3
Determine the priority nursing intervention based on the ABC framework.
The nurse must prioritize Breathing by obtaining oxygenation data and immediately escalate the Circulation failure to the registered nurse.
Impending septic shock is a medical emergency requiring rapid intervention (e.g., intravenous fluids, antibiotics) that necessitates registered nurse and provider involvement.

Key Concept

Recognizing early signs of septic shock and prioritizing ABCs in older adults with acute delirium.
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Topics

Physiological Adaptation

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