During morning rounds on a medical-surgical unit, a practical nurse (PN) assesses a client who underwent an open bowel resection two days ago. The client appears restless and mildly confused. Assessment findings include a heart rate of 115 beats/minute, a respiratory rate of 24 breaths/minute, and a blood pressure of 94/56 mm Hg. A review of the morning electronic health record reveals a newly resulted serum lactate level of 4.8 mmol/L (normal range: 0.5-1.0 mmol/L). The client's baseline blood pressure from the previous shift was 130/72 mm Hg. Which of the following actions should the PN take first?
- Immediately escalate the client's vital signs and laboratory results to the supervising registered nurse.Answer
- BReassess the client's vital signs in one hour, as the heart rate and blood pressure changes are minor.
- CWithhold further action until the healthcare provider reviews the elevated serum lactate during afternoon rounds.
- DIncrease the rate of the continuous intravenous fluids to treat the client's decreasing blood pressure.
Answer
Immediately escalate the client's vital signs and laboratory results to the supervising registered nurse.
The client is demonstrating early signs of shock and physiological deterioration, including tachycardia, relative hypotension, tachypnea, restlessness, and a critically elevated serum lactate. The priority for the practical nurse is to recognize these combined indicators of risk and immediately escalate the findings to the supervising registered nurse so that timely life-saving interventions can be initiated.
Step-by-Step Solution
Key Concept
Early Recognition and Escalation of Shock/Sepsis