A nurse is caring for a client in an acute care setting.
Nurses’ Notes.
Day 1. 1400:. Day 2. Client has paraplegia and reports, “I have had a cough the last.
few days.
I haven’t had an appetite either.” Denies nausea,. vomiting, or diarrhea.
Alert and oriented to person, place, and.
time.
Skin is intact.
Vital signs stable.
1830:. Client is experiencing tachycardia, productive cough, and.
confusion.
Vital Signs.
Day 1. 1400:. Temperature 36.9° C (98.4° F). Pulse 76/min.
Respiratory rate 20/min.
BP 128/68 mm Hg. Oxygen saturation on room air 95%. Day 2. 1830:. Temperature 38.4° C (101.1° F). Heart rate 105/min.
Respiratory rate 24/min.
BP 132/80 mm Hg. Oxygen saturation on room air 89%. Diagnostic Results.
Day 1. 1400:. Hgb 11.0 g/dL (12 to 16 g/dL). Hct 38% (37% to 476). WBC count 12,500/mm³ (5,000 to 10,000/mm?). Complete the following sentence by using the list of options.
The client is at risk for? Select from Options 1 – as evidenced by the client’s Select from Options 2. Select from Options 1 .
A.
Hypostatic pneumonia.
B.
Anemia.
C.
Fluid volume overload.
D.
Immobility.
F.
Calorie deficiency.
The correct answer and Explanation is :
The client is at risk for A. Hypostatic pneumonia as evidenced by the client’s productive cough, tachycardia, confusion, and decreased oxygen saturation.
Explanation:
Hypostatic pneumonia, also known as aspiration pneumonia, is a type of lung infection that can occur in patients with limited mobility, such as those with paraplegia. This condition arises due to the accumulation of secretions in the lungs, which can become infected. The patient’s decreased mobility makes them particularly susceptible to this type of pneumonia because they may have difficulty clearing secretions effectively.
Key Clinical Indicators:
- Productive Cough: The presence of a productive cough is significant as it indicates that the patient is trying to clear secretions from the lungs. In the context of hypostatic pneumonia, the cough is often accompanied by purulent sputum.
- Tachycardia: An elevated heart rate (tachycardia) can be a response to fever and infection. It reflects the body’s increased effort to manage the infection.
- Confusion: This can be a sign of systemic infection or a decreased level of oxygenation affecting mental status. It is crucial to consider changes in mental status as they may indicate worsening respiratory function or systemic involvement.
- Decreased Oxygen Saturation: The drop in oxygen saturation to 89% from a baseline of 95% suggests compromised respiratory function, which can be due to pneumonia or another respiratory condition.
The other options are less likely to be the primary concern in this scenario:
- B. Anemia: The hemoglobin level (11.0 g/dL) is slightly below normal, but not dramatically so. While anemia can contribute to fatigue and potentially worsen respiratory conditions, it is not the immediate concern here.
- C. Fluid Volume Overload: The vital signs and history do not strongly indicate fluid overload.
- D. Immobility: While immobility is a risk factor for developing hypostatic pneumonia, the immediate risk is more directly related to the symptoms being observed.
- F. Calorie Deficiency: The client’s lack of appetite does not directly explain the respiratory symptoms and confusion observed.
Thus, based on the clinical presentation and vital signs, the most pressing risk for the client is hypostatic pneumonia.