After receiving report on an inpatient acute care unit, which client should the nurse assess first?

Rationale for Correct Choices:

• Sickle cell crisis: The infant’s pallor, edema in hands and feet, irritability, poor feeding, decreased urine output, and recent infection align with a vaso-occlusive episode typical in sickle cell disease.

•IV and oral fluids decrease blood viscosity and improve circulation, which is essential to prevent worsening of vaso-occlusion and associated pain.

• As able, elevate extremities: Elevating affected extremities promotes venous return, reduces swelling, and alleviates discomfort during the crisis.

• Intake and output: Monitoring fluid balance is critical to detect dehydration or renal compromise, which are risks in sickle cell crises due to reduced perfusion and poor intake.

• White blood cell count: WBC monitoring helps detect infection, which can trigger or worsen a sickle cell crisis, and assesses the body’s inflammatory response during the acute event.

Rationale for Incorrect Choices:

• Leukemia: While leukemia can present with pallor and fatigue, the acute swelling of hands and feet, irritability, and trigger by recent infection are more characteristic of sickle cell crisis rather than leukemia.

• Pneumonia: Adventitious lung sounds are noted, but the primary presenting signs (pallor, extremity edema, decreased urine output, pain) are more consistent with sickle cell crisis; pneumonia alone would not explain extremity edema.

• Potential Condition: Stroke: Stroke in infants may cause focal neurological deficits or asymmetric movement, but this infant shows generalized extremity involvement without focal weakness, making stroke less likely.

• Initiate sliding scale insulin: There is no evidence of hyperglycemia requiring insulin; blood glucose monitoring is not indicated for the acute presentation.

• Cool the environment: Cooling can worsen vasoconstriction and precipitate a sickle cell crisis; it is contraindicated in vaso-occlusive episodes.

• Begin bilirubin light therapy: The infant does not present with jaundice or hyperbilirubinemia; phototherapy is not indicated.

• Blood glucose: There is no indication of hypoglycemia or hyperglycemia contributing to this presentation, so monitoring glucose is not priority.

• Clotting times: There is no evidence of coagulopathy or bleeding disorder in this scenario; monitoring clotting times is unnecessary.

• Bilirubin: The infant has no jaundice or lab evidence of hyperbilirubinemia, making bilirubin monitoring nonessential.

A. Assist client to a supine position: The initial step in assessing orthostatic hypotension is to have the client lie supine for several minutes. This allows baseline blood pressure and heart rate to be measured in a stable, resting position before changing posture.

B. Instruct the client to stand upright: Standing too soon without establishing baseline measurements may place the client at risk for falls or injury due to dizziness or sudden blood pressure changes.

C. Place the client in a semi-Fowler's position: A semi-Fowler’s position is partially upright, which does not provide an accurate baseline for assessing orthostatic changes compared to the supine position.

D. Help the client sit on the side of the bed: Sitting at the bedside is part of the assessment sequence, but it should occur after obtaining supine baseline readings to safely monitor changes in blood pressure and heart rate.