Question

Multiple-choice question: Which of the following assessments is a priority nursing concern? A. Heart rate of 168 B. Respiratory rate of 54 C. Irritability D. One wet diaper in 24 hours

Short answer

The correct answer is B. A Respiratory rate of 54 is extremely high, even for an infant, indicating Tachypnea, which should be considered as a priority.

Step-by-step solution

Recognize the Indications

Each option needs to be scrutinized based on its gravity. Identify the normal range for these parameters: Resting Heart Rate for adults is 60-100 beats per minute (bpm), for infants up to 1 year is around 70-160 bpm. The normal Respiratory rate for adults is 12-20 breaths per minute and for infants is typically counted to 30-60 breaths per minute. An uncomfortable mood is hard to quantify but it's always important to ensure patient comfort. As for the infant's urine output, a bare minimum would be 1 wet diaper every 3 hours.

Evaluate Each Option

After recognizing the indicators, each option is evaluated. (A) The Heart rate of 168 is definitely high, even for an infant, this indicates Tachycardia. (B) A Respiratory rate of 54 is alarmingly high even for an infant, revealing Tachypnea. (C) Irritability can be the result of various factors and its impact varies based on the reason behind it. Nonetheless, it's not immediately life-threatening. (D) One wet diaper in a whole day is not enough, this could point out Dehydration or Urinary problems.

Rank the Options

Rank the options based on the severity and urgency. The abnormal heart rate and abnormal respiratory rates are powerful immediate threats to life. Due to the significance of air to life, B is high rank. Then, comes in A, the Tachycardia. Followed by D, possible Dehydration, which can become a concern over time. Lastly, C, irritability, which requires patient consolation.

Key concepts

Nursing Assessments

Nursing assessments are the cornerstone of effective patient care. This process involves gathering comprehensive information about a patient's health status. It's a continuous practice aimed at identifying any potential or actual health problems a patient may face.

A thorough nursing assessment includes evaluating a patient's physical condition, behavior, and physiological parameters. Nurses must consider a variety of factors, such as age, symptoms, and vital signs, to form a complete picture of the patient's health.

• Physical Examination: This often requires observing the patient, checking vital signs like temperature, pulse, and blood pressure, and assessing physical capabilities.
• Observing Behavior: Noting any signs of distress or discomfort, such as irritability, which provides clues to the patient's condition.
• Evaluating Vital Signs: Critical benchmarks include heart rate, respiratory rate, and urine output, helping to identify any urgent health issues.

Effective nursing assessment is crucial in prioritizing patient needs, especially when managing conditions such as tachycardia and tachypnea.

Tachycardia

Tachycardia is a condition characterized by an abnormally fast heartbeat. In infants, a heart rate above 160 beats per minute (bpm) may be considered tachycardic. Despite the higher baseline heart rate in infants compared to adults, a heart rate of 168 bpm should raise concerns.

This condition can be caused by several factors and it's crucial to determine whether the tachycardia is a normal physiological response or a sign of a more serious underlying issue. Common causes include:

• Fever: Elevated body temperature can increase heart rate.
• Dehydration: Lack of adequate fluids can lead to a rapid pulse.
• Anxiety or Pain: Emotional distress or discomfort can also increase heart rate.
• Cardiac Issues: While less common, congenital heart defects or other cardiac problems should be considered.

It's important for nurses to monitor the infant's heart rate and look for any accompanying symptoms that may indicate a need for immediate medical attention.

Tachypnea

Tachypnea refers to an unusually rapid rate of breathing. For infants, a respiratory rate over 60 breaths per minute is considered tachypnea. It is an indication that the infant's body is working harder than normal to breathe. This can be a response to various conditions.

Causes of tachypnea can vary widely from normal physiological reactions to pathological conditions. These may include:

• Respiratory Infection: Conditions like pneumonia or bronchiolitis can result in rapid breathing.
• Fever: As the body attempts to cool through breath evaporation, the respiratory rate may increase.
• Metabolic Acidosis: Conditions where the body produces excess acid can accelerate breathing.
• Heart Issues: Similar to tachycardia, cardiac problems could lead to compensatory rapid breathing.

It's essential for healthcare professionals to recognize and assess tachypnea promptly since it often points to serious underlying health concerns requiring swift intervention.

Infant Urine Output

Infant urine output is an important indicator of their hydration status and kidney function. Adequate urine output is essential for removing waste and maintaining a healthy fluid balance.

In general, an infant should wet about 6 to 8 diapers in a day. The presence of only one wet diaper in 24 hours could suggest dehydration or renal issues, which could become critical if not addressed in time. Potential causes may include:

• Dehydration: This can occur due to inadequate fluid intake or excessive fluid loss, such as from fever or diarrhea.
• Urinary Tract Obstruction: Physical blockages that impede urine flow.
• Kidney dysfunction: Issues with renal function can impact urine production.

Monitoring urine output is a simple yet vital part of a nursing assessment, as it can provide early signs of more complex health issues requiring intervention.