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Zorluk: Çok zorPhysiological Adaptation

While evaluating a 79-year-old client being treated for a severe lower extremity soft tissue infection, the practical nurse notes a sudden change in the client's behavior. The client, who was previously alert and cooperative, is now acutely disoriented and continuously picking at their intravenous tubing. The most recent vital signs demonstrate a temperature of 96.8°F (36.0°C), a heart rate of 108 bpm, a blood pressure of 102/62 mm Hg, and a respiratory rate of 24/min. The client's morning baseline blood pressure was 134/76 mm Hg. Which of the following actions should the practical nurse perform first?

  1. Apply a pulse oximeter to assess oxygenation and elevate the head of the bed.Cevap
  2. B
    Implement strict fall precautions and instruct the client's family to provide frequent verbal reorientation.
  3. C
    Review the client's medication administration record to determine if recently administered analgesics are causing adverse effects.
  4. D
    Record the vital sign measurements in the medical record and plan to reassess the client's hemodynamic status in one hour.

Cevap

The practical nurse should first apply a pulse oximeter and elevate the head of the bed to immediately assess and support the client's airway and breathing.
The correct answer addresses the immediate physiological priority using the ABC (Airway, Breathing, Circulation) framework. Acute confusion in an older adult is a classic early sign of hypoxia or decreased cerebral perfusion, often preceding overt respiratory failure or cardiovascular collapse. The client's tachypnea, tachycardia, relative hypotension (a severe drop from baseline), and hypothermia point to a systemic infection progressing to septic shock. Assessing oxygenation and optimizing breathing by elevating the head of the bed is the most critical first step.

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1
Analyze the clinical data and the client's baseline.
The client has an active infection and is exhibiting acute confusion, tachypnea, mild tachycardia, relative hypotension (a significant drop from baseline), and hypothermia.
Recognizing trends and deviations from baseline is crucial, as these are hallmark signs of systemic inflammatory response syndrome (SIRS) progressing to sepsis or septic shock in an older adult.
2
Apply the ABC (Airway, Breathing, Circulation) prioritization framework.
The sudden onset of confusion combined with a respiratory rate of 24/min suggests potential hypoxia and inadequate cerebral perfusion.
Physiological needs related to oxygenation and systemic perfusion always take precedence over environmental safety, documentation, or pharmacological investigations.
3
Determine the immediate nursing action within the practical nurse scope of practice.
Assessing oxygen saturation and positioning the client to optimize lung expansion is the immediate priority.
This directly addresses the immediate threat to the client's respiratory and neurological status, gathering critical data before escalating the rapidly deteriorating situation to the registered nurse.

Anahtar Kavram

Early Recognition of Septic Shock and ABC Prioritization
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Konular

Physiological Adaptation

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