A nurse is caring for a client Medical History.
A client is receiving chemotherapy for treatment of colon cancer Laboratory Results.
Week 1:
WBC count 8,000/mm (5,000 to 11,000/mm) Platelets 350,000/mm (150,000 to 400,000/mm) Potassium 3.7 mEq/L (3.5 to 5 mEq/L)
Week 2:
WBC count 3,800/mm (5,000 to 10,000/mm) Platelets 150,000/mm (150,000 to 400,000/mm) Potassium 3.6 mEq/L (3.5 to 5 mEq/L)
Vital Signs.
Week 2:
Temperature 38.6° C (101.5° F) BP 114/56 mm Hg
Heart rate 102/min
Respiratory rate 24/min
Oxygen saturation is 93% on room air Nurses’ Notes.
Week 1:
Bilateral breath sounds clear upon auscultation in all lobes Week 2:
Bilateral breath sounds with crackles were heard at the bases
A nurse is reviewing the client’s electronic medical record. Which of the following findings requires follow-up?
Select all that apply.
A.
Potassium level.
B.
Temperature.
C.
WBC count.
D.
Breath sounds.
E.
Blood pressure.
The Correct answer and Explanation is:
In the given scenario, the findings that require follow-up are:
B. Temperature
C. WBC count
D. Breath sounds
Explanation:
Temperature (B): The client’s temperature is elevated at 38.6°C (101.5°F). This fever is significant, especially for a patient undergoing chemotherapy. Chemotherapy can impair the immune system, making patients more susceptible to infections. A fever in this context could indicate an underlying infection, which requires prompt evaluation and management to prevent further complications. A follow-up is necessary to determine the cause of the fever and to initiate appropriate treatment, such as antibiotics, if an infection is present.
WBC Count (C): The client’s WBC count has decreased from 8,000/mm³ in Week 1 to 3,800/mm³ in Week 2, which is below the normal range (5,000 to 10,000/mm³). This decrease is indicative of leukopenia, a common side effect of chemotherapy that compromises the immune system. Leukopenia increases the risk of infections and requires monitoring. The healthcare provider may need to assess the client’s risk of infection and potentially adjust the treatment plan or provide supportive measures to address this condition.
Breath Sounds (D): The presence of crackles at the bases of the lungs, as noted in Week 2, indicates potential pulmonary issues such as fluid accumulation, which could be a side effect of chemotherapy or a sign of an infection like pneumonia. This finding requires follow-up to determine the cause and initiate appropriate interventions. Further assessment, such as a chest X-ray or additional respiratory evaluation, may be necessary.
Potassium Level (A): The potassium level of 3.7 mEq/L is within the normal range (3.5 to 5 mEq/L) and does not require follow-up at this time.
Blood Pressure (E): The blood pressure reading of 114/56 mm Hg is within acceptable limits and does not show signs of abnormality that would necessitate immediate follow-up based on the provided information.
In summary, the most urgent follow-ups are related to the fever, decreased WBC count, and abnormal breath sounds, as these findings can have significant implications for the client’s overall health and treatment plan.