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Zorluk: OrtaPhysiological Adaptation

A 74-year-old client is admitted with an exacerbation of chronic obstructive pulmonary disease (COPD) and is receiving oxygen at 2 L/min via nasal cannula. During a routine check, the practical nurse (PN) observes that the client is newly agitated, attempting to pull off the oxygen tubing, and confused about their location. The client's heart rate is 108 beats/min and blood pressure is 102/64 mm Hg. Which action should the PN take first?

  1. Measure the oxygen saturation and observe the client's respiratory effort.Cevap
  2. B
    Administer the prescribed as-needed analgesic to decrease the client's agitation.
  3. C
    Gently reorient the client to the hospital room and the need for the oxygen therapy.
  4. D
    Document the borderline vital signs and continue to closely monitor the client's behavior.

Cevap

Measure the oxygen saturation and observe the client's respiratory effort.
In an older adult with a respiratory condition, new-onset agitation, confusion, and restlessness are frequently the earliest indicators of hypoxia. According to the ABC (Airway, Breathing, Circulation) framework, the practical nurse must immediately prioritize respiratory data collection—such as oxygen saturation and respiratory effort—to determine if the client's physiological condition is acutely deteriorating.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client has a history of COPD and is presenting with new-onset agitation, confusion, and mild tachycardia (HR 108).
Identifying acute changes from baseline is essential for early recognition of physiological deterioration.
2
Correlate the symptoms with potential physiological causes.
In older adults, restlessness and sudden confusion are classic early signs of hypoxia (inadequate oxygenation to the brain), not just behavioral issues.
The brain is highly sensitive to drops in oxygen; altered mental status is often the first cue before cyanosis or severe vital sign collapse occurs.
3
Apply the ABC (Airway, Breathing, Circulation) prioritization framework.
Before intervening with medications or psychological support, the PN must gather data related to 'Breathing'.
Measuring oxygen saturation and work of breathing provides objective data to confirm hypoxia and guide emergency interventions or RN notification.

Anahtar Kavram

Recognizing early signs of hypoxia and prioritizing respiratory data collection
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Konular

Physiological Adaptation

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