A nurse is caring for a client.
Exhibit 1 Vital Signs 0800: Exhibit 2 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 Select the 4 findings that require immediate follow-up.
A.
Temperature
B.
Blood pressure
C.
Respiratory rate
D.
Pulse oximetry.
E.
Heart rate.
F.
Level of consciousness
G.
Skin color and temperature
The Correct answer and Explanation is:
Correct Answers:
B. Blood pressure
C. Respiratory rate
D. Pulse oximetry
E. Heart rate
Explanation:
In this scenario, a nurse is monitoring a client’s vital signs, and certain changes require immediate follow-up due to the potential for clinical deterioration.
1. Blood Pressure:
The client’s blood pressure (BP) dropped from 108/56 mm Hg at 0800 to 88/56 mm Hg at 0830. This decrease in systolic BP by 20 mm Hg is significant and may indicate the onset of hypotension. Hypotension can reduce perfusion to vital organs, leading to tissue hypoxia and organ failure if not addressed promptly. The diastolic pressure remained the same, which might suggest peripheral vasodilation without an effective compensatory increase in cardiac output. This is concerning and requires immediate follow-up.
2. Respiratory Rate:
The client’s respiratory rate increased from 18/min to 24/min. A rise in respiratory rate is often an early indicator of distress, such as hypoxia or metabolic acidosis. It can also reflect compensatory mechanisms for underlying conditions such as sepsis, shock, or pulmonary embolism. Therefore, this change necessitates further investigation to determine the underlying cause.
3. Pulse Oximetry:
The client’s oxygen saturation decreased from 97% on room air to 93% on room air. Although 93% is still within an acceptable range, the drop from 97% is concerning, especially when combined with the other changes in vital signs. It suggests that the client may be experiencing early hypoxia, which can lead to more significant respiratory compromise if not addressed.
4. Heart Rate:
The heart rate increased from 66/min to 104/min, which is a considerable rise. This tachycardia could be a compensatory response to hypotension, hypoxia, or other forms of physiological stress. A heart rate over 100/min is considered abnormal and, when seen with other concerning signs (like hypotension and hypoxia), may indicate the development of a life-threatening condition such as shock or sepsis.
Summary:
The combination of hypotension, tachycardia, increased respiratory rate, and decreased oxygen saturation suggests that the client is experiencing a systemic issue, such as shock, sepsis, or another form of acute deterioration. Immediate follow-up is required to assess and address the underlying cause to prevent further clinical decline. Monitoring and supportive interventions, such as fluid resuscitation, oxygen therapy, and possibly advanced hemodynamic support, may be necessary depending on the diagnosis.