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Difficulty: HardPhysiological Adaptation

An 8484-year-old client resides in a skilled nursing facility and is currently receiving oral antibiotics for a lower respiratory tract infection. During the night shift, the practical nurse (PN) finds the client repeatedly attempting to climb out of bed. The client is disoriented to place and time, which is an acute change from their baseline. The client's current vital signs are: Temperature 97.4∘F97.4^\circ\text{F} (36.3∘C36.3^\circ\text{C}), Heart Rate 116116 bpm, Respiratory Rate 2424 breaths/min, and Blood Pressure 96/5896/58 mm Hg. Which of the following actions should the practical nurse take FIRST?

  1. Obtain an oxygen saturation reading, elevate the head of the bed, and immediately notify the registered nurse.Answer
  2. B
    Continue to monitor the client routinely, as the slightly elevated heart rate and lower blood pressure are expected during sleep.
  3. C
    Dim the room lights and gently reorient the client, attributing the confusion to age-related sundowning.
  4. D
    Administer the client's prescribed as-needed analgesic medication to relieve potential discomfort causing the restlessness.

Answer

Obtain an oxygen saturation reading, elevate the head of the bed, and immediately notify the registered nurse.
The client is exhibiting acute delirium alongside tachypnea, tachycardia, and borderline hypotension. In an older adult with a known infection, this presentation strongly suggests physiological adaptation failure, specifically early sepsis or hypoxia. The priority is to address Airway, Breathing, and Circulation (ABC) by assessing oxygenation, repositioning to support respiratory effort, and immediately escalating to the registered nurse for further medical intervention.

Step-by-Step Solution

1
Analyze the client's symptoms and recent medical history.
The client has a respiratory infection and is presenting with new-onset delirium, tachypnea, tachycardia, and borderline hypotension.
Identifying the cluster of symptoms helps distinguish between a chronic psychological issue and an acute physiological crisis.
2
Evaluate the vital signs against the client's baseline and age expectations.
A heart rate of 116116 bpm and blood pressure of 96/5896/58 mm Hg, combined with a lower body temperature, are not normal sleep parameters and suggest early shock or sepsis.
Recognizing subtle or borderline vital sign changes is critical for early intervention in geriatric populations.
3
Determine the priority nursing action based on the ABC (Airway, Breathing, Circulation) framework.
The priority is to assess respiratory function (oxygen saturation), support breathing (elevate head of bed), and escalate the critical findings to the RN.
Physiological survival needs always take precedence over comfort measures or routine monitoring when an acute deterioration is suspected.

Key Concept

Recognition and prioritization of early sepsis and hypoxia in the geriatric client.
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Topics

Physiological Adaptation

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