80 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.
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