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Which of  these Assessment Findings this morning suggest delirum, and why is it important to know for nursing? Increased fatigue over the past 3 days Alert and oriented X 2-disoriented to place this morning  Anxious and distressed Dyspnea and SOB Accessory muscle use Breath sounds diminished to bases bilaterally  Productive cough with green blood-tinges sputum—difficulty expectorating  Expiratory wheeze bilaterally Barrel chest  Skin is pale, hot and dry  Strong peripheral pulses  Urine is clear and concentrated with U/O 100 cc overnight Intermittent chills  Fingernails are yellow with clubbing present

Health Science Feb 23, 2023

Which of  these Assessment Findings this morning suggest delirum, and why is it important to know for nursing?

  • Increased fatigue over the past 3 days
  • Alert and oriented X 2-disoriented to place this morning 
  • Anxious and distressed
  • Dyspnea and SOB
  • Accessory muscle use
  • Breath sounds diminished to bases bilaterally 
  • Productive cough with green blood-tinges sputum—difficulty expectorating 
  • Expiratory wheeze bilaterally
  • Barrel chest 
  • Skin is pale, hot and dry 
  • Strong peripheral pulses 
  • Urine is clear and concentrated with U/O 100 cc overnight
  • Intermittent chills 
  • Fingernails are yellow with clubbing present

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