Question

The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120 , and respirations 20 . Which is the client's most appropriate priority nursing diagnosis? A. Alteration in cerebral tissue perfusion B. Fluid volume deficit C. Ineffective airway clearance D. Alteration in sensory perception

Short answer

Answer: B. Fluid volume deficit

Step-by-step solution

Assess the vital signs

First, let's take a look at the client's vital signs. They have a blood pressure (BP) of 80/34, a pulse rate of 120, and a respiration rate of 20. The BP is low, the pulse rate is high, and the respiration rate is normal (12-20 breaths per minute).

Consider Option A

Option A is "Alteration in cerebral tissue perfusion". This diagnosis relates to the blood flow to the brain. While a low BP could affect cerebral tissue perfusion and a high heart rate can indicate compensation for inadequate perfusion, there is not enough information to determine if this is the primary issue for the client.

Consider Option B

Option B is "Fluid volume deficit". This diagnosis is related to a decreased intravascular, interstitial, and/or intracellular fluid in the body. The low BP and elevated pulse rate can be indicative of a fluid volume deficit, especially since the client has been involved in a motor vehicle accident. This option seems more likely to be the priority diagnosis.

Consider Option C

Option C is "Ineffective airway clearance". This diagnosis relates to the inability to clear secretions or obstructions from the respiratory tract. However, the client's respiration rate is normal (20 breaths per minute), which indicates that airway clearance is not the primary issue.

Consider Option D

Option D is "Alteration in sensory perception". This diagnosis is related to changes in the way the client processes sensory stimuli. While this could be a potential diagnosis, there is no information about any sensory perception changes or issues in the given assessment findings.

Make a conclusion

Based on the given assessment findings (low BP, high pulse rate, and normal respiration rate), and considering each option, it appears that the most appropriate priority nursing diagnosis for this client would be: B. Fluid volume deficit This diagnosis aligns with the client's low blood pressure and elevated heart rate, both of which can indicate a decreased fluid volume in the body due to the motor vehicle accident.

Key concepts

Nursing Diagnosis

A nursing diagnosis is a clinical judgment about a patient's response to actual or potential health conditions or needs. These diagnoses are crucial within the nursing process as they guide interventions and provide a foundation for goal setting and comprehensive care planning. The primary purpose of a nursing diagnosis is to pave the way for effective treatment and better patient outcomes. For instance, in the case of this motor vehicle accident, assessing the patient's symptoms such as low blood pressure and a high pulse rate can lead to the determination of 'Fluid Volume Deficit' as a priority diagnosis. This step helps in setting targeted interventions like fluid replacement therapy and monitoring the patient’s vital signs more frequently to ensure stability.

Vital Signs Assessment

Vital signs are measurements of the body's most basic functions. Knowing a patient’s vital signs allows healthcare professionals to determine the normal range for the individual and recognize any changes that might indicate a deterioration in health. In this context, the key components of vital signs include:

• Blood Pressure (BP): A normal range is usually between 90-120 for systolic and 60-80 for diastolic. In our case, the BP of 80/34 indicates hypotension, which is a cause for concern.
• Pulse Rate: Normal resting heart rate for adults ranges from 60 to 100 beats per minute. A pulse rate of 120 suggests tachycardia, often a compensatory mechanism for low blood volume.
• Respiration Rate: Typically falls within 12-20 breaths per minute. At 20, the patient’s rate is at the high end but still within normal limits.

Assessing these signs provides critical information about the patient's cardiovascular and respiratory status and guides healthcare providers in planning immediate care.

Emergency Nursing Care

Emergency nursing care involves immediate and rapid assessment and management of patients who present with acute or life-threatening conditions. In an emergency setting, such as following a motor vehicle accident, nurses need to quickly ascertain and stabilize vital signs, identify immediate medical needs, and commence appropriate interventions. Key priorities in emergency nursing care include:

• Stabilization of Vital Signs: Ensuring the patient is hemodynamically stable is critical. This might involve fluid resuscitation, medications, or other interventions.
• Pain Management: Addressing any discomfort due to injuries is a primary concern to improve patient outcomes.
• Continuous Monitoring: Vital signs should be frequently reassessed to detect any rapid changes in the patient's condition.

Prompt responses and the ability to prioritize interventions are essential skills for nurses in these environments to ensure safe and effective patient care.

Fluid Volume Deficit

Fluid volume deficit occurs when there is an inadequate amount of fluid in the circulatory system, which can lead to decreased blood pressure and increased heart rate as compensatory mechanisms by the body. This condition can be caused by factors such as excessive fluid loss due to bleeding, as in the case of a motor vehicle accident. Signs and symptoms of fluid volume deficit include:

• Hypotension (low blood pressure)
• Tachycardia (rapid heart rate)
• Decreased urine output
• Dry mucous membranes

Managing fluid volume deficit requires prompt intervention, typically involving the administration of intravenous fluids to restore adequate circulation. Monitoring fluid intake and output, along with the regular assessment of vital signs, is crucial to ensure effective correction of the deficit. Understanding the underlying causes, recognizing symptoms early, and initiating appropriate care are key aspects of managing fluid volume deficit effectively.