In assessing which of the client's findings would be of immediate concern, we can analyze the provided data from the nurse's notes and the client's vitals:
1. Cardiac assessment: The EKG shows sinus tachycardia with a heart rate of 114 beats per minute. Tachycardia is a condition where the heart rate is higher than normal, and it needs monitoring, as it can be a sign of underlying conditions or stress on the heart, especially in a trauma patient.
2. Respiratory assessment: The respiratory rate is noted to be 24, which is higher than the normal range for adults (12-20 breaths per minute). Additionally, the breathing is described as shallow. Even though the pulse oximetry reading is 98%, the elevated respiratory rate and shallow breathing could indicate respiratory distress or other respiratory issues.
3. Cast assessment: The cast status after the femur surgery is “Fiber cast dry/intact,” and while this is generally a routine follow-up item, it needs regular monitoring to ensure there is no swelling, compromised circulation, or other complications under the cast.
Based on this information, the findings of immediate concern would be:
- Cardiac assessment
- Cast assessment
- Respiratory assessment
Therefore, the client's findings of immediate concern are:
- Cardiac assessment
- Cast assessment
- Respiratory assessment
These areas need continuous monitoring to ensure that any potential complications are detected and managed promptly.
