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Zorluk: Çok zorPhysiological Adaptation

While assessing a client recovering from a chronic obstructive pulmonary disease (COPD) exacerbation, the practical nurse notes a sudden change in the client's baseline behavior. The 78-year-old client, who has been treated with high-dose intravenous corticosteroids for the past three days, is now highly agitated, disoriented, and reports a burning sensation in the epigastric region. The vital signs show a heart rate of 115 bpm, a blood pressure of 102/56 mm Hg, and an oxygen saturation of 89% on room air. What is the priority intervention for the practical nurse in this scenario?

  1. Initiate supplemental oxygen therapy and immediately notify the registered nurse of the changing condition.Cevap
  2. B
    Administer the prescribed as-needed antacid for the epigastric pain and evaluate its effectiveness.
  3. C
    Record the vital signs in the electronic health record and maintain the current plan of care.
  4. D
    Apply a bed alarm and dim the room lights to manage the acute disorientation.

Cevap

Initiate supplemental oxygen therapy and immediately notify the registered nurse of the changing condition.
The client is exhibiting signs of a severe gastrointestinal bleed, a known complication of high-dose corticosteroid therapy (indicated by the epigastric pain). The combination of agitation, tachycardia (115 bpm), borderline hypotension (102/56 mm Hg), and hypoxia (SpO2 89%) indicates impending hypovolemic shock and poor tissue perfusion. The practical nurse must prioritize ABCs (Airway, Breathing, Circulation) by applying oxygen to treat the hypoxia and immediately escalating the situation to the registered nurse for rapid medical intervention.

Adım Adım Çözüm

1
Analyze the clinical cues, including the history of corticosteroid use, epigastric pain, and new-onset agitation.
Identify that these findings suggest a potential gastrointestinal bleed.
Corticosteroids significantly increase the risk of peptic ulcers. Sudden bleeding can lead to decreased cerebral perfusion, causing the acute agitation.
2
Evaluate the current vital signs (Heart rate 115 bpm, Blood pressure 102/56 mm Hg, SpO2 89%).
Recognize that the client is experiencing hypoxia and early signs of hypovolemic shock.
Tachycardia and a narrowing or dropping blood pressure are compensatory mechanisms for volume loss, while hypoxia results from decreased oxygen-carrying capacity.
3
Determine the priority nursing action based on the ABC framework (Airway, Breathing, Circulation) and the practical nurse scope of practice.
Select the intervention that addresses oxygenation and rapidly involves the registered nurse.
Applying oxygen directly treats the breathing deficit, and a rapidly decompensating client requires immediate RN-level assessment and collaborative intervention.

Anahtar Kavram

Recognizing early signs of hypovolemic shock secondary to gastrointestinal bleeding and prioritizing ABCs (Airway, Breathing, Circulation).
Tahmini Süre:1m 30s
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Physiological Adaptation

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