Mr. Teban is a 73-year old patient diagnosed with pneumonia. Which data would be of greatest concern to the nurse when completing the nursing assessment of the patient?
A. Alert and oriented to date, time, and place.
B. Buccal cyanosis and capillary refill greater than 3 seconds.
C. Clear breath sounds and nonproductive cough.
D. Hemoglobin concentration of 13 g/dl and leukocyte count 5,300/mm3.
Correct Answer: B. Buccal cyanosis and capillary refill greater than 3 seconds.
Buccal cyanosis and capillary refill greater than 3 seconds are indicative of decreased oxygen to the tissues, which requires immediate intervention. As oxygenation and perfusion become impaired, peripheral tissues become cyanotic. Cyanosis of nail beds may represent vasoconstriction or the body’s response to fever/chills; however, cyanosis of earlobes, mucous membranes, and skin around the mouth (“warm membranes”) is indicative of systemic hypoxemia. Alert and oriented, clear breath sounds, nonproductive cough, hemoglobin concentration of 13 g/dl, and leukocyte count of 5,300/mm3 are normal data.
Option A: Restlessness, irritation, confusion, and somnolence may reflect hypoxemia and decreased cerebral oxygenation and may require further intervention. Check pulse oximetry results with any mental status changes in older adults.
Option C: Decreased airflow occurs in areas with consolidated fluid. Bronchial breath sounds can also occur in these consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasms and obstruction.
Option D: Monitor serial chest x-rays, ABGs, pulse oximetry readings. Follows progress and effects and extent of pneumonia. Therapeutic regimen, and may facilitate necessary alterations in therapy. Oxygen saturation should be maintained at 90% or greater. Imbalances in PaCO2 and PaO2 may indicate respiratory fatigue.