A nurse is caring for a client who has a hip and pelvis fracture. On Day 1 at 1100, the nurse documents the following: Client admitted from the emergency department after falling at home. Client reports pain 7/10 in right hip and lower back. Alert and oriented to person, place, and time Bilateral breath sounds are clear Pedal pulses +2: skin is pink and warm to touch movement and sensation intact to extremities Reddened and ecchymotic areas noted on the middle to Slight edema to sacral and lilac region present Temp 97.5 F. HR 92. RR 22. BP 146/05. O2 Sat 95% On Day 2 at 0945, the nurse documents the following: Client unable to void and bladder is distended. Indwelling urinary catheter inserted; draining dark, reddish colored urine; Edema to sacral and iliac region 2+. Lower extremities cool to touch, pedal pulses absent bilaterally, capillary refill time >6 seconds. Temp 98.9 F, HR 108, RR 24, BP 154/78, 02 Sat 96% pain reported at 10/10. Which finding requires IMMEDIATE follow-up?
Explanation & Rationale
A. Breath sounds on Day 1: Bilateral clear breath sounds indicate adequate ventilation and oxygenation. There are no signs of respiratory compromise, so this finding does not require immediate intervention. B. Capillary refill on Day 2: A capillary refill time greater than 6 seconds, absent pedal pulses, and cool lower extremities indicate compromised perfusion and possible vascular occlusion or acute limb ischemia. This is an urgent finding requiring immediate follow-up to prevent permanent tissue damage. C. Temperature on Day 2: A temperature of 98.9°F is within normal limits or only slightly elevated. While it should be monitored for trends, it does not constitute an immediate threat to the patient’s condition. D. Neuro status on Day 1: The client was alert and oriented to person, place, and time on Day 1, indicating normal neurologic function. This finding does not require immediate intervention.