While working in a skilled nursing facility, a practical nurse receives a report from an assistive personnel regarding an older adult resident with a healing stage 3 sacral pressure injury. The resident is described as unusually difficult to awaken and suddenly disoriented to place. Current vital signs reveal a blood pressure of 94/58 mmHg, a heart rate of 114 beats/min, a respiratory rate of 24 breaths/min, and a tympanic temperature of 96.2°F (35.7°C). Based on these assessment data, what is the most appropriate initial action for the practical nurse to take?
- Communicate the clinical changes to the supervising registered nurse for urgent evaluation.Answer
- BRecord the vital signs in the client chart and plan to recheck them at the next scheduled interval.
- CProvide verbal reorientation and instruct the staff to minimize environmental stimulation.
- DPrepare and administer the prescribed as-needed oral analgesic to address potential wound discomfort.
Answer
Communicate the clinical changes to the supervising registered nurse for urgent evaluation.
The client's presentation of sudden confusion, hypothermia, tachycardia, and borderline hypotension strongly suggests the onset of sepsis, likely originating from the sacral pressure injury. In older adults, infection often presents atypically with hypothermia and altered mental status rather than a fever. Because these vital signs indicate impending hemodynamic instability and distributive shock, the practical nurse must prioritize communicating these changes to the supervising registered nurse immediately to initiate life-saving interventions.
Step-by-Step Solution
Key Concept
Recognition of Sepsis and Shock in Older Adults
Estimated Time:1m 15s