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Difficulty: Very hardEstablishing Priorities

During a multidisciplinary safety huddle, the rapid response team (RRT) reviews electronic health record alerts triggered for clients across the hospital. Which of the following client alerts indicate an acute, unstable deterioration requiring the RRT's immediate intervention? (Select all that apply.)

  1. A client 1212 hours post-splenectomy whose vital signs show a blood pressure of 106/86106/86 mm Hg and a heart rate of 118118 bpm.Answer
  2. B
    A client with an acute exacerbation of chronic obstructive pulmonary disease (COPD) whose arterial blood gas reveals a pH of 7.347.34, PaCO2\text{PaCO}_2 of 5858 mm Hg, and PaO2\text{PaO}_2 of 6161 mm Hg.
  3. A client receiving a continuous intravenous heparin infusion who reports a sudden, 'thunderclap' headache and new-onset diplopia.Answer
  4. D
    A client with chronic heart failure who exhibits 2+2+ dependent pitting edema, a 2.22.2 lb (11 kg) weight gain over 4848 hours, and a B-type natriuretic peptide (BNP) of 720720 pg/mL.
  5. A client with severe acute pancreatitis who demonstrates carpopedal spasms during noninvasive blood pressure monitoring and reports circumoral tingling.Answer

Answer

The clients requiring immediate intervention are the post-splenectomy client with a narrow pulse pressure, the client on heparin with a sudden headache, and the pancreatitis client with carpopedal spasms.
The correct clients require immediate, life-saving intervention. A narrow pulse pressure (2020 mm Hg) with tachycardia in a post-surgical client indicates early hemorrhagic shock. A sudden 'thunderclap' headache and diplopia in a client on heparin signals a life-threatening intracranial hemorrhage. Finally, carpopedal spasms (Trousseau's sign) and circumoral tingling in a pancreatitis client indicate severe hypocalcemia, which can rapidly cause fatal cardiac arrhythmias or airway-blocking laryngospasm.

Step-by-Step Solution

1
Analyze each client presentation to differentiate between expected chronic disease manifestations and acute, life-threatening deteriorations.
Clients with unexpected, critical physiological cues require priority intervention based on the Airway-Breathing-Circulation (ABC) framework.
Establishing priorities ensures critical resources are allocated to clients with the highest risk of immediate morbidity or mortality.
2
Evaluate the hemodynamic status of the post-splenectomy client.
The client exhibits a narrow pulse pressure (106−86=20106 - 86 = 20 mm Hg) and tachycardia (118118 bpm), indicating early hemorrhagic shock.
A narrowing pulse pressure is a subtle but highly critical early sign of compensatory shock, requiring immediate evaluation for internal bleeding.
3
Evaluate the neurological status of the client receiving continuous heparin.
The sudden 'thunderclap' headache and diplopia strongly indicate a potential intracranial hemorrhage.
Systemic anticoagulation carries a severe risk of bleeding; abrupt neurological deficits represent a life-threatening emergency requiring immediate cessation of the infusion.
4
Evaluate the neuromuscular symptoms of the client with acute pancreatitis.
Carpopedal spasms (Trousseau's sign) and circumoral tingling indicate profound, symptomatic hypocalcemia.
Severe hypocalcemia can rapidly progress to life-threatening laryngospasm, tetany, or cardiac arrhythmias, necessitating immediate intravenous calcium replacement.
5
Identify the expected/chronic findings in the remaining clients.
The COPD client has compensated respiratory acidosis, and the heart failure client displays signs of chronic fluid overload.
While abnormal, these are expected baseline manifestations for their respective chronic disease processes and do not require rapid response intervention compared to the highly unstable clients.

Key Concept

Prioritizing Unstable Clients with Acute, Unexpected Findings
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Establishing Priorities

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