87 Case Study 1: Adult Client (continued)

1. Which findings are considered abnormal for this adult client? What medical terminology is used to define/label these findings?

• The temperature is higher than expected: hyperthermia/febrile (> 37.3°C)
• The pulse in lying position is within normal limits, but in the sitting and standing position, the pulse is elevated and is identified as tachycardia (> than 100 bpm)
• The pulse increased more than 20 bpm and the systolic BP decreased more than 20 mm Hg when the client moved from lying to standing, indicating orthostatic hypotension
• The pulse is weak and thready at 1+ force, which is abnormal
• The respiration rate is high: tachypnea (> 20 bpm)
• The oxygen saturations are slightly low (< 97%)

2. What further assessment should the healthcare provider do based on this adult client’s findings?

Continue to assess for signs of dehydration:

• Dry mucous membranes
• Poor skin turgor
• Decreased and concentrated urine output

3. What actions should the healthcare provider take based on this adult client’s findings?

• Notify the most responsible provider such as the physician or nurse practitioner.
• If you are the most responsible provider, discuss and initiate treatments such as fluid rehydration.