A charge nurse delegates to an assistive personnel (AP) the task of ambulating a client. At the end of the shift, the nurse discovers the client has not been ambulated. Which of the following actions should the nurse take first?

Rationale for correct choices

• Blurred vision: Amitriptyline is a tricyclic antidepressant that has anticholinergic effects, which can reduce the ability of the eyes to focus and cause blurred vision. Clients should be warned about potential difficulty with reading or driving until they know how the medication affects their vision. This adverse effect is common and may persist throughout therapy.

• Orthostatic hypotension Amitriptyline can block alpha-adrenergic receptors, leading to vasodilation and a drop in blood pressure upon standing. Clients may experience dizziness, lightheadedness, or fainting, especially when moving from sitting to standing. Monitoring blood pressure and educating the client to rise slowly are important preventive strategies.

• Urinary retention Anticholinergic effects of amitriptyline can impair bladder contraction, causing difficulty initiating urination or incomplete emptying. This is particularly important in older adults or clients with preexisting urinary issues. Teaching clients to report urinary hesitancy or discomfort helps prevent complications such as infection.

• Constipation Amitriptyline slows gastrointestinal motility due to its anticholinergic properties, making constipation a common adverse effect. Clients may need dietary adjustments, increased fluid intake, or stool softeners. Early teaching on prevention is important to reduce discomfort and maintain regular bowel habits.

Rationale for incorrect choices

• Tinnitus: Tinnitus is not commonly associated with amitriptyline therapy. While some medications can cause ringing in the ears, this is not a primary concern with tricyclic antidepressants. It is less likely to be observed or require teaching.

• Sore throat: Sore throat is not a known adverse effect of amitriptyline. Upper respiratory symptoms are unrelated to the anticholinergic and adrenergic effects of this medication, making this an inappropriate teaching point.

• Bradycardia: Amitriptyline does not typically cause bradycardia; it may instead affect conduction and potentially lead to arrhythmias in susceptible clients, but slowing the heart rate is uncommon. Monitoring focuses on blood pressure rather than heart rate reduction.

• Peripheral edema: Peripheral edema is not a common effect of amitriptyline. Fluid retention is not typically induced by tricyclic antidepressants, so this is not a relevant teaching point.

• Increased urination: Amitriptyline generally causes urinary retention rather than increased urination due to anticholinergic effects. Increased urination is not expected and is not a priority to include in client teaching.

• Dysuria: While urinary retention can cause discomfort, dysuria (painful urination) is not a direct effect of amitriptyline. Any urinary pain would likely be secondary to infection, not the medication itself.

• Diarrhea: Amitriptyline slows gastrointestinal motility, so diarrhea is not a common effect. Constipation is far more likely due to anticholinergic activity.

• Nausea with vomiting: Although some clients may experience mild nausea initially, constipation is more directly linked to the anticholinergic mechanism and is more consistent as a common teaching point. Nausea is less frequent and usually transient.

Rationale:

A. Respiratory therapist: A respiratory therapist is essential in arranging home oxygen by evaluating the client’s respiratory needs, determining appropriate oxygen flow rates, and ensuring proper use of equipment. They also provide education on safety and maintenance, which is critical for clients newly diagnosed with COPD who must manage oxygen therapy at home.

B. Physical therapist: A physical therapist focuses on mobility and strength training, which can benefit clients with COPD but is not directly responsible for arranging or coordinating home oxygen therapy. Their role becomes more relevant after respiratory support is established and the client begins working on endurance and safe activity levels.

C. Social worker: A social worker assists with social support, financial resources, and coping needs but is not typically involved in arranging clinical respiratory equipment. Their involvement may be helpful later if the client requires community services, but they are not the primary referral for initiating oxygen therapy.

D. Case manager: A case manager plays a key role in long-term discharge planning and may eventually coordinate services, but the immediate need for oxygen setup requires a respiratory therapist’s specialized assessment. Once the respiratory plan is initiated, the case manager can support broader continuity of care needs.