Question

Your assessment findings are as follows: Vital signs 94/72, 109, 32, 100.80 F (38.2 C), Spo2 89% on room air. You auscultate decreased breath sounds and coarse crackles in the left lower lobe posteriorly. M.M. is alert and oriented to name. He does not answer all your questions and is unable to follow simple instructions. There is minimal eye contact and he continues to look furtively out the window. The rest of his assessment is remarkable. You believe his delirium may be associated with hypoxia and fever from atelectasis.

What is the focus of the ongoing assessment you need to perform?

Answer 1

       The assessment finding of a patient; vital signs bp 94/72,pulse 109, respiration 32, temperature 100.80F and showed decreased breath sounds and coarse crackles in left lower lobe.The patient showed only minimal eye contact. Hence I believed that patient has hypoxia and fever from atelectasis.

        Hypoxia is a condition in which lack of oxygen supply in the body. Atelectasis is a condition in which the alveoli or whole lobes or the lungs are collapsed.

       Assessment for hypoxia  

         * Assess for anxiety ,restlessness and confusion.

         * Monitor BP for early detection of hypotension.

         * Assess for activity tolerance and level of consciousness.

         * Assess the signs of cyanosis such as bluish discolouration in skin,lips and mucous membrane.

         * Check hemoglobin level.

      Assessment for Atelectasis

         * Assess for shortness of breath, wheezing or cough.

         * Assess and monitor respiratory rate as it can be elevated.

         * Assess for shallow breathing pattern.

         * Assess body temperature, as they can develop fever.