Question

A nurse is caring for a client who is experiencing delirium.

History and Physical
Day 1 0800:
75-year-old client who has osteoarthritis of the knees. Reports increased pain to the right knee following their daily walk of 3 miles. History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism. No known allergies.
Nurses' Notes
Day 3 0800:
Client is postoperative day three from right knee arthroplasty. Currently with operative knee in the continuous passive motion (CPM) machine but attempting to take knee out of device. States, "I've had enough of this mess. I'm going home." Client is disoriented to time and place, oriented to self. Refuses to answer simple questions, rambles incoherently when spoken to. Will not follow simple commands. Client's family is at bedside and reports the client began displaying behavior changes the prior evening. States that client was awake most of the night and was restless when they did fall asleep, appeared to be having nightmares. Attempted to get out of bed without assistance during the early morning hours.
Surgical dressing to right knee dry and intact. No sign of redness or edema around the dressing. Client refuses to answer questions about surgical pain or respond to prompts using pain scales. According to client's family, client has not received pain medication since before physical therapy yesterday afternoon and has not reported pain.
Requested client's family to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance.
Placed call to provider to report findings. Awaiting call-back.
Day 3 0900:
Return call from client's provider, update given, prescriptions received. Upon entering client's room, find client attempting to get out of bed. Client's family is trying to stop them. Client is agitated and disoriented to place, attempting to pull out IV device, becomes incontinent of urine in the bed. Client's family states, "That has never happened before."
Reassurance offered to client and their family. Assistive personnel called to help with bathing client and changing linens. Client calmer following hygiene and comfort measures. States having knee pain of 5 on a scale of 0 to 10.
Requested client's family member to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance.
Day 3 0930:
Administered hydrocodone for report of knee pain. Client resting quietly at this time. Family members at bedside.
Graphic Record
Day 3 0800:
Heart rate 115/min
Respiratory rate 20/min
Blood pressure 90/48 mm Hg
Temperature 38.6° C (101.5° F)
Oxygen saturation 96% on room air
Weight 63.5 kg (140 lb)
Intake and Output (I&O)I = 750 mLO = 2,500 mL
Provider Prescriptions
Day 1:
Enoxaparin 30 mg subcutaneously twice daily
Levothyroxine 75 mcg PO once daily
Omeprazole 20 mg PO once daily
Pravastatin 40 mg PO once daily at bedtime
Morphine 2 to 4 mg intermittent IV bolus every 4 hr PRN pain
Hydrocodone 5 mg PO every 6 hr PRN pain
Acetaminophen 325 mg PO every 6 hr PRN pain or temperature greater than 38.3° C (101° F)
Day 3 0900:Daily weight
IV bolus of 0.9% sodium chloride 150 mL/hr for first 4 hr, then decrease to 75 mL/hr
Encourage PO fluids
Urine for urinalysis and culture and sensitivity
Discontinue morphine
Melatonin 1 mg PO 2 hr before bedtime
Diagnostic Results
Day 3 0800:
Capillary blood glucose 92 mg/dL (82 to 115 mg/dL)
The nurse is planning care for the client who has delirium and new prescriptions. Complete the following sentence by using the lists of options.
The nurse should first ___1___, followed by ___2___.
Options for 1
A) Obtain a urine sample
B) Administer melatonin
C) Initiate IV fluids
Options for 2
A) Administering acetaminophen
B) Preparing discharge teaching
C) Weighing the client

Answer 1

The nurse should first initiate IV fluids to stabilize the client's vital signs and then obtain a urine sample to investigate possible causes of delirium, such as a UTI (option C and A respectively).

Step-by-step explanation:

The nurse should prioritize interventions for this client who is experiencing delirium post knee arthroplasty. The client's hypotension (90/48 mm Hg) and tachycardia (HR 115/min), coupled with the recent surgical procedure and symptoms of delirium, suggest that the first action should be C) Initiate IV fluids as prescribed by the provider to address possible dehydration and stabilize vital signs. This is a priority because it directly addresses the physiological instability that may be contributing to the delirium.

Following the initiation of IV fluids, the nurse should focus on A) Obtain a urine sample as ordered by the provider for urinalysis and culture and sensitivity, to investigate possible causes of delirium such as a urinary tract infection (UTI), which is a common and treatable cause of acute confusion in elderly patients.

Additional interventions such as administering acetaminophen or weighing the client are important but are of lower priority compared to physiological stabilization and investigation of the underlying cause of the delirium. Once the immediate safety concerns are addressed and a possible infection is being investigated, other prescriptions can be administered as needed and further care planning can be done.

Hence, the answer is option C and A respectively.