A nurse is assisting with the care of a 15-year-old adolescent who has Streptococcus pneumonia. Exhibits The nurse is collecting data on the adolescent 24 hr later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the admitting diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
Explanation & Rationale
Steatorrhea: Steatorrhea (fatty stools) is a common symptom of cystic fibrosis due to pancreatic insufficiency. It is not directly related to the current acute infection (Streptococcus pneumonia). Barrel chest: A barrel chest is a chronic sign of cystic fibrosis caused by long-standing lung disease and airway obstruction. It is not related to the acute infection (Streptococcus pneumonia) but reflects the long-term effects of cystic fibrosis. Hemoptysis 300 mL: Hemoptysis, 300 mL, is a significant and concerning sign of potential worsening condition. While blood-streaked sputum was initially noted, a large volume like 300 mL indicates significant bleeding from the lungs. WBC count 17,000/mm³: The initial WBC count was 22,000/mm3, indicating an active bacterial infection. A decrease to 17,000/mm3, while still elevated, suggests that the body's inflammatory response is potentially improving and that the infection IS responding to treatment. Oxygen saturation 95% on 1 L oxygen via nasal cannula: The oxygen saturation has improved (from 92% to 95%) with a reduction in the amount of supplemental oxygen, indicating that the patient’s respiratory status is improving. Respiratory rate 32/min: The respiratory rate has decreased slightly from 36/min to 32/min, indicating that the patient’s breathing is becoming more stable as the condition improves. However, respiratory rate should still be closely monitored as part of overall progress.