Fundamentals of Nursing Q 396
Nurse Stephanie is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all that apply.
A. Restlessness
B. Tachypnea
C. Bradycardia
D. Confusion
E. Cyanosis
Correct Answer: A, B, & E
Restlessness, tachypnea, and pallor are early manifestations of hypoxemia, along with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds. Bradycardia and confusion are late manifestations of hypoxemia, along with stupor, cyanotic skin and mucous membranes, bradypnea, hypotension, and cardiac dysrhythmias. Hypoxemia is defined as a decrease in the partial pressure of oxygen in the blood whereas hypoxia is defined by reduced level of tissue oxygenation. It can be due to either defective delivery or defective utilization of oxygen by the tissues.
Option A: When oxygen delivery is severely compromised, organ function will start to deteriorate. Neurologic manifestations include restlessness, headache, and confusion with moderate hypoxia. In severe cases, altered mentation and coma can occur, and if not corrected quickly may lead to death.
Option B: The chronic presentation is usually less dramatic, with dyspnea on exertion as the most common complaint. Symptoms of the underlying condition that induced the hypoxia can help in narrowing the differential diagnosis. The physical exam may show tachypnea and low oxygen saturation. Fever may point to infection as the cause of hypoxia.
Option C: Bradycardia is a late manifestation of hypoxemia. Increase in cardiac output with exercise results in accelerated blood flow through alveoli, reducing the time available for gas exchange. In case of the abnormal pulmonary interstitium, gas exchange time becomes insufficient, and hypoxemia ensues.
Option D: Both confusion and somnolence may occur in respiratory failure. Myoclonus and seizures may occur with severe hypoxemia. Polycythemia is a complication of long-standing hypoxemia.
Option E: Cyanosis, a bluish color of skin and mucous membranes, indicates hypoxemia. Visible cyanosis typically is present when the concentration of deoxygenated hemoglobin in the capillaries of tissues is at least 5 g/dL.