James White, a patient with an exacerbation of chronic obstructive pulmonary disease (COPD), is on your medical-surgical unit. You need to obtain his vital signs and give him a bath. His vital signs at 0800 were as follows: temperature, 98.4°F; pulse, 86 beats/min and regular; respirations, 18 breaths/min; blood pressure, 130/68 mm Hg. The physical therapist who is working with this patient on conditioning therapy has just brought him back from his exercises. You notice that his breathing is labored, with audible expiratory wheezes. While you are obtaining his oral temperature and vital signs, you continue to hear audible expiratory wheezing. His vital signs now are as follows: temperature, 96.8°F; pulse, 106 beats/min and irregular; respirations, 26 breaths/min; blood pressure, 140/74 mm Hg.
Prescribed Interventions
- Daily physical therapy for conditioning
- Oxygen at 2 L via nasal prongs prn for pulse oximetry ;90%
- Vital signs q4h
- Oxygen saturation levels via pulse oximeter every shift and prn
Developing Clinical Reasoning and Clinical Judgment
- Did you take the second set of vital signs at the most appropriate time? Why or why not?
- Describe the timing and type of bath you think Mr. White requires and the degree of assistance he will need. Explain your rationale.
- How has Mr. White's physical activity affected the accuracy of his vital signs?
- What would be your course of action in response to his labored breathing?
Suggested Responses for Integrated Nursing Care
- Always compare vital signs with the baseline before making further clinical decisions (refer to Chapter 2). As you compare the previous vital signs with the ones you just obtained, you notice that Mr. White's pulse rate, respiratory rate, and blood pressure are elevated. Your assessment of his pulse also indicates that his pulse is now irregular. Mr. White has just experienced a significant increase in activity; waiting until he has recovered from the exertion would be more appropriate in order to obtain a resting set of vital signs.
- What does the very low temperature indicate? Remember, you continued to hear Mr. White's heavy breathing while obtaining the remainder of the vital signs. Mr. White could not keep his lips pursed in a seal around the thermometer, and this often gives an inaccurate temperature (refer to Chapter 2). Mouth breathing and respiratory distress are contraindications for obtaining an oral temperature. As a nurse, you are responsible for determining the most appropriate site to obtain the temperature (refer to Chapter 2).
- Does Mr. White's elevated respiratory rate and noisy breathing indicate respiratory distress or a need for oxygen? Obtain an oxygen saturation level via pulse oximetry (refer to Chapter 14). If the oxygen saturation level is satisfactory for Mr. White, then you can be confident that his body is compensating for the increased oxygen demand. Allow him to rest, with the head of his bed elevated, and retake his vital signs in 15 to 30 minutes. Take vital signs as often as the patient's condition warrants. If Mr. White's oxygen saturation and vital signs continue to deviate from baseline after a rest period, obtain additional information through a more focused respiratory assessment and notify the health care provider (refer to Chapters 2, 3, and 14).
- A bath represents another increase in activity. Mr. White needs time to recover from the physical therapy exercises before attempting the bath. He should be able to sit in a chair and, in fact, will breathe more comfortably sitting up than lying down. Having him lie flat could make him decompensate (deterioration in respiratory function), so you should not perform occupied bed-making (refer to Chapter 7). If encouraged to sit up, he will probably be able to complete much of his bath by himself.