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Zorluk: ZorData Collection Techniques

A practical nurse (PN) is gathering focused data on a 78-year-old client residing in a long-term care facility. The assistive personnel (AP) reports that the client, who is typically calm, has suddenly begun pacing the halls, appearing disoriented, and crying out intermittently. Which of the following data collection techniques and actions are appropriate for the PN to implement? Select all that apply.

  1. Obtaining a midstream urine specimen to test for the presence of leukocytes or nitritesCevap
  2. Checking oxygen saturation using a pulse oximeter on a well-perfused digitCevap
  3. C
    Documenting the new behavior as an expected progression of age-related cognitive decline
  4. Measuring a complete set of vital signs, including blood pressure and core temperatureCevap
  5. E
    Asking the client directly, 'Why are you pacing and crying out today?' to gather subjective data
  6. F
    Applying soft wrist restraints temporarily to ensure safety while conducting the physical assessment

Cevap

The correct actions are obtaining a midstream urine specimen, checking oxygen saturation, and measuring a complete set of vital signs.
Sudden-onset disorientation and agitation in an older adult strongly suggest acute delirium, which is frequently caused by physiological stressors like urinary tract infections, hypoxia, or systemic illness. Appropriate data collection involves immediately gathering physical data—such as vital signs, oxygen saturation, and a urinalysis—to identify the underlying physiological cause so it can be promptly reported to the registered nurse (RN) or provider.

Adım Adım Çözüm

1
Differentiate between dementia and delirium based on the scenario.
The client's symptoms represent a sudden, acute change from their calm baseline, which is a hallmark indicator of delirium rather than chronic dementia.
Recognizing that sudden behavioral changes indicate an acute physiological issue dictates the need for immediate, targeted physical data collection.
2
Identify non-invasive data collection techniques to uncover physiological causes.
Techniques include assessing vital signs, pulse oximetry (for hypoxia), and urinalysis (for urinary tract infections).
Infection and hypoxia are two of the most common causes of acute delirium in the older adult population.
3
Eliminate inappropriate or unsafe data collection techniques.
Discarding options that suggest non-therapeutic communication ('why' questions), normalization of the symptom, or the premature use of physical restraints.
Safe and effective care requires therapeutic communication and adherence to legal guidelines regarding restrictive devices.

Anahtar Kavram

Data Collection Techniques for Acute Delirium in the Older Adult
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Data Collection Techniques

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