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Difficulty: HardPhysiological Adaptation

An 82-year-old client is admitted to the acute care facility for treatment of a severe urinary tract infection. During the shift assessment, the practical nurse (PN) notes the client is restless and disoriented to place, which is a change from baseline. The client's heart rate is 118 beats per minute, respirations are 26 breaths per minute, blood pressure is 92/54 mm Hg, and oral temperature is 96.4°F (35.8°C). Which actions should the PN take? Select all that apply.

  1. Notify the registered nurse (RN) immediately regarding the client's assessment findings.Answer
  2. Verify the patency of the client's current intravenous access site.Answer
  3. Prepare to assist the RN with administering a rapid isotonic fluid bolus.Answer
  4. D
    Request a prescription for an anti-anxiety medication to manage the client's restlessness.
  5. E
    Document the disorientation as a routine finding associated with advanced age.
  6. F
    Reassess the client's vital signs during the next scheduled round in four hours.

Answer

The correct actions are to immediately notify the RN regarding the findings, verify the patency of the intravenous access, and prepare to assist with a rapid isotonic fluid bolus.
The client's presentation of tachycardia, tachypnea, hypotension, hypothermia, and acute confusion in the presence of an infection indicates early septic shock. The practical nurse must prioritize life-saving circulation support. This involves immediately notifying the RN to initiate emergency protocols, ensuring patent IV access for medication delivery, and preparing for rapid volume expansion with isotonic fluids to restore blood pressure and organ perfusion.

Step-by-Step Solution

1
Analyze the clinical data.
The client has a known infection and is presenting with tachycardia, tachypnea, hypotension, hypothermia, and new-onset disorientation.
Identifying abnormal findings is the first step in clinical judgment.
2
Interpret the meaning of the combined findings.
The constellation of symptoms indicates systemic inflammatory response syndrome (SIRS) progressing into early septic shock with compromised tissue perfusion.
Older adults may present with atypical signs of sepsis, such as hypothermia and altered mental status, rather than a high fever.
3
Determine the appropriate PN interventions based on priorities.
The priority is to recognize the emergency, escalate care to the RN, and prepare for immediate resuscitative measures like fluid volume expansion.
Airway, breathing, and circulation (ABC) take precedence. Interventions must aim to rapidly restore hemodynamic stability.

Key Concept

Recognizing and prioritizing care for septic shock and physiological decompensation in older adults.
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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