A nurse is caring for a client.
Vital Signs
0800:
Temperature 37.6° C (99.7 F) Blood pressure 108/56 mm Hg Heart rate 66/min Respiratory rate 18/min
Pulse oximetry 97% on room air 0830:
Temperature 37.5° C (99.5° F) Blood pressure 88/56 mm Hg Heart rate 104/min Respiratory rate 24/min
Pulse oximetry 93% on room air Nurses’ Notes
0800:
Antibiotic administered as prescribed.
Bilateral breath sounds clear and present throughout. 0830
Client reports itching over the chest area and has urticaria over chest and trunk.
Client states tongue feels swollen
Bilateral breath sounds with scattered wheezing upon auscultation, Select the 4 findings that require immediate follow-up.
A.
Heart rate
B.
Blood pressure
C.
Temperature
D.
Urticaria
E.
Swollen tongue
F.
Breath sounds
The Correct answer and Explanation is:
The correct findings that require immediate follow-up are:
A. Heart rate
B. Blood pressure
E. Swollen tongue
F. Breath sounds
Explanation:
The scenario presented indicates that the client is experiencing signs and symptoms of a possible severe allergic reaction, which could escalate to anaphylaxis. Anaphylaxis is a life-threatening condition that requires immediate intervention. Let’s analyze the findings that require immediate follow-up:
- Heart Rate (104/min): The significant increase in heart rate from 66/min at 0800 to 104/min at 0830 is a critical change. Tachycardia can indicate the body’s response to stress, including allergic reactions. This sudden rise suggests a compensatory mechanism to maintain adequate perfusion in response to a potential drop in blood pressure and oxygenation.
- Blood Pressure (88/56 mm Hg): The drop in blood pressure from 108/56 mm Hg to 88/56 mm Hg is another alarming sign. Hypotension is a hallmark of anaphylaxis and indicates that the cardiovascular system is failing to maintain adequate perfusion to vital organs, which can lead to shock if not promptly addressed.
- Swollen Tongue: The client’s report of a swollen tongue is particularly concerning. Swelling of the tongue can signify angioedema, which can obstruct the airway, leading to respiratory distress or failure. This symptom is a red flag for anaphylaxis and requires immediate action to secure the airway and prevent asphyxiation.
- Breath Sounds (scattered wheezing): The development of scattered wheezing indicates that the client’s airway is becoming compromised. Wheezing is a sign of bronchoconstriction, which is common in anaphylaxis. It reflects narrowing of the airways and can rapidly progress to respiratory failure if not treated immediately.
The other findings, such as temperature (which remains stable) and urticaria (which is a typical symptom of an allergic reaction but not immediately life-threatening on its own), are noteworthy but not as critical as the changes in vital signs, swollen tongue, and wheezing.
Immediate Actions:
Given these findings, the nurse should immediately administer epinephrine, provide supplemental oxygen, ensure IV access for fluid resuscitation, and prepare for advanced airway management if needed. Quick identification and treatment of anaphylaxis are crucial to preventing severe complications or death.