A 78-year-old client residing in a skilled nursing facility suddenly develops acute confusion, agitation, and new-onset urinary incontinence. The nurse enters the client's room and observes the client attempting to climb over the bed rails. In what order should the nurse prioritize the following actions? (Arrange the actions from highest to lowest priority.)
- 1Implement immediate safety measures and assist the client back to a safe position.
- 2Obtain a full set of vital signs, including oxygen saturation and temperature.
- 3Perform a focused neurological and cognitive assessment.
- 4Assess for potential localized triggers, such as bladder distention or signs of infection.
- 5Communicate the findings to the healthcare provider using the SBAR communication tool.
Answer
1. Implement immediate safety measures
2. Obtain vital signs
3. Perform focused neurological assessment
4. Assess for potential localized triggers
5. Communicate findings to the provider
2. Obtain vital signs
3. Perform focused neurological assessment
4. Assess for potential localized triggers
5. Communicate findings to the provider
In older adults, acute changes such as confusion and incontinence often indicate an underlying pathology rather than normal aging. The nurse must prioritize care using the nursing process and safety frameworks. Immediate physical safety is the highest priority for an agitated client attempting to leave the bed. Following safety, assessing physiological stability (vital signs and oxygenation) is the next priority to rule out life-threatening causes of delirium like hypoxia. Once stable, a focused neurological assessment quantifies the acute change, followed by assessing for localized triggers (such as urinary issues). Finally, with all assessment data gathered, the nurse is fully prepared to notify the provider.
Step-by-Step Solution
Key Concept
Prioritization of Care for Acute Delirium in Older Adults