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Question

Difficulty: HardPhysiological Adaptation

An 82-year-old client was admitted to the medical unit two days ago for treatment of a severe urinary tract infection. The client, who had been completely alert and oriented since admission, is suddenly restless, unable to state their current location, and attempting to pull out their intravenous (IV) catheter. The client's baseline blood pressure on admission was 142/84 mm Hg. Current data collection reveals a blood pressure of 100/60 mm Hg, heart rate of 112 beats/min, respiratory rate of 24 breaths/min, and a temperature of 97.2°F (36.2°C). Which action is the priority for the practical nurse?

  1. Notify the registered nurse immediately regarding the acute change in mental status and vital sign trends.Answer
  2. B
    Reorient the client to the room and provide a calming environment, as temporary confusion is an expected hospital complication for older adults.
  3. C
    Apply bilateral soft wrist restraints to prevent the client from dislodging the necessary intravenous catheter.
  4. D
    Document the findings in the medical record, as a blood pressure of 100/60 mm Hg remains within a generally acceptable adult range.

Answer

Notify the registered nurse immediately regarding the acute change in mental status and vital sign trends.
The correct action is to immediately notify the registered nurse. The client is demonstrating classic signs of early septic shock: a significant decrease in blood pressure from their baseline, tachycardia, tachypnea, and a sudden alteration in mental status. In older adults, sudden restlessness or confusion is frequently the first presenting sign of a severe physiological complication like systemic infection or hypoxia. The practical nurse must prioritize recognizing these subtle but critical cues and escalating care to prevent complete hemodynamic collapse.

Step-by-Step Solution

1
Analyze the client's current mental status against their baseline.
The client has transitioned from alert and oriented to confused and restless.
Sudden changes in level of consciousness in older adults are critical early indicators of systemic issues like hypoxia, infection, or decreased cerebral perfusion.
2
Compare the current vital signs to the admission baseline data.
The blood pressure has dropped significantly (systolic down 42 points), heart rate is elevated (112), and respiratory rate is elevated (24). Temperature is slightly subnormal, which can occur in sepsis.
Recognizing relative hypotension (a drop from the client's specific baseline) is essential, rather than relying solely on standard reference ranges.
3
Synthesize the data to determine the underlying physiological process.
The combination of the UTI history, altered mental status, relative hypotension, tachycardia, and tachypnea strongly suggests the client is entering early septic shock.
Identifying the pattern of impending shock determines the urgency of the required response.
4
Determine the priority nursing intervention within the practical nurse scope of practice.
The situation requires immediate escalation to the registered nurse or rapid response team.
Hemodynamic instability requires rapid assessment, fluid resuscitation, and potential medication administration that falls under RN and provider responsibilities.

Key Concept

Recognition of Early Septic Shock and Borderline Vitals in Older Adults
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Topics

Physiological Adaptation

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