22. Nurse Stevens is conducting a home visit for Mrs. Clarke, a patient with advanced lung cancer. During the assessment, Nurse Stevens notes wheezing, bradycardia, and a respiratory rate of 10 breaths per minute. These symptoms are indicative of which condition?
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EXPLANATION
✔Correct answer:
Hypoxia. The symptoms observed in Mrs. Clarke—wheezing, bradycardia (slow heart rate), and a respiratory rate of 10 breaths per minute—are indicative of hypoxia. Hypoxia refers to a deficiency in the amount of oxygen reaching the tissues. In patients with advanced lung cancer, hypoxia can occur due to several reasons, such as obstructed airways, impaired gas exchange, or reduced lung capacity.
Hypoxia occurs when there is insufficient oxygen in the blood to meet the metabolic demands of the body's tissues. In patients with lung cancer, tumors can obstruct airways or cause pleural effusion, leading to decreased oxygenation. The body responds to hypoxia by initially increasing the respiratory rate; however, as the condition progresses and the respiratory muscles fatigue, the rate may decrease, leading to bradycardia and other signs of severe oxygen deprivation.
Think of hypoxia like a car running out of fuel. Initially, the car may sputter and slow down, and if not refueled, it will eventually stop. Similarly, the body initially tries to compensate for low oxygen by increasing breathing efforts, but if the oxygen levels continue to drop, the body's vital functions, like heart rate and respiratory rate, will slow down.
Nurse Stevens should take immediate action to address the hypoxia:
- Administer supplemental oxygen as prescribed to improve oxygen saturation levels.
- Position Mrs. Clarke in a semi-Fowler’s position to facilitate easier breathing.
- Monitor vital signs closely, including respiratory rate, heart rate, and oxygen saturation.
- Assess for any signs of airway obstruction and manage according to protocol (e.g., suctioning if necessary).
- Notify the healthcare provider of the patient's condition to consider further interventions, such as medication adjustments or additional diagnostic tests.
✘Incorrect answer options:
Delirium Delirium is characterized by acute confusion, disorientation, and fluctuations in consciousness. While it can occur in patients with advanced illness, it is not directly indicated by the respiratory and cardiovascular symptoms described (wheezing, bradycardia, and a low respiratory rate).
Hyperventilation Hyperventilation involves rapid or deep breathing that leads to decreased levels of carbon dioxide in the blood. Symptoms typically include a high respiratory rate, tingling in the extremities, and dizziness, which are not consistent with Mrs. Clarke's presentation.
Semiconsciousness Semiconsciousness refers to a state where a patient is partially but not fully aware of their surroundings. While hypoxia can lead to altered levels of consciousness, the specific symptoms of wheezing, bradycardia, and low respiratory rate more directly point to hypoxia as the underlying cause rather than semiconsciousness as a primary condition.
References
- Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Wolters Kluwer.
- Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.