The nurse is aware the early indicator of hypoxia in the unconscious client is:
A. Cyanosis
B. Increased respirations
C. Hypertension
D. Restlessness
Correct Answer: D. Restlessness
Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in an unconscious client who suddenly becomes restless. 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 A: Cyanosis is the bluish discoloration of the tissues that results from increased concentration of reduced hemoglobin. This may be a late indication of hypoxia. Sufficiently severe hypoxia can result in tachycardia to provide sufficient oxygen to the tissues. Some of the signs are very evident on physical exam; stridor can be heard once the patient arrives in cases of upper airway obstruction. Skin can be cyanotic, which might indicate severe hypoxia.
Option B: Hypoxia induces a breathing pattern of rapid and shallow breaths with a relatively higher increase in respiratory rate than tidal volume. This is more noticeable in conscious patients. 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.
Option C: Pulmonary hypoxic hypertension is associated with high pressure in the blood vessels of the lungs, caused by a shortage of oxygen in the body. This is a late sign of hypoxia. The 6-minutes walk test is frequently used in the preoperative pulmonary evaluation, pulmonary hypertension treatment and assessment of supplemental oxygen need with exercise.