A client who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

- Potential Condition:

Stage 2 pressure injury

- Actions to Take:

C. Clean the area and dry carefully: Proper wound care involves cleaning the area to prevent infection and promote healing. Cleaning the erythematous area on the left heel and ensuring
it is dry can help prevent further skin breakdown and promote healing.

B. Hold the hydrochlorothiazide: Hydrochlorothiazide is a diuretic that can increase urine output and potentially lead to dehydration, which may exacerbate the client's condition. Holding the medication temporarily can help prevent further fluid loss and dehydration, which is crucial for wound healing.

- Parameters to Monitor:

B. Skin color: Monitoring the skin color around the erythematous area on the left heel can help assess tissue perfusion and identify any signs of deterioration or improvement in the wound condition.
D. Fluid balance: Monitoring the client's fluid balance, including intake and output, is essential for assessing hydration status and ensuring adequate tissue perfusion, which is vital for wound healing and overall patient well-being.

Actions to Take:

A. Educate on disease process and management: Rheumatoid arthritis (RA) is a chronic

autoimmune disorder characterized by inflammation of the synovial membrane, leading to joint pain, swelling, and stiffness. Educating the client about RA helps them understand the disease, its

progression, treatment options, and the importance of adherence to prescribed medications and lifestyle modifications. This empowers the client to actively participate in managing their condition and improve outcomes.

B. Turn every two hours to offload bony prominences to prevent pressure injuries: Rheumatoid arthritis predisposes individuals to joint deformities and immobility due to joint inflammation and pain. Immobility increases the risk of pressure injuries, especially over bony prominences. Turning the client every two hours helps redistribute pressure, reduces the risk of pressure ulcers, and maintains skin integrity.

Potential Condition:

D. Rheumatoid arthritis: The client's clinical presentation, including bilateral joint pain and stiffness, positive rheumatoid factor, positive antinuclear antibody test, elevated erythrocyte sedimentation rate (ESR), and soft tissue swelling with marginal erosions on hand X-rays, is consistent with rheumatoid arthritis (RA). RA is a chronic autoimmune disease characterized by inflammation of the synovial joints, leading to joint damage, pain, and functional impairment.

Parameters to Monitor:

C. Pain: Monitoring pain is essential in rheumatoid arthritis management to assess the effectiveness of pain management interventions and adjust treatment accordingly. Pain assessment tools, such as numerical rating scales or visual analog scales, help quantify pain intensity and guide pain management strategies.

D. Skin breakdown: Rheumatoid arthritis can limit mobility and predispose individuals to prolonged immobility, increasing the risk of pressure injuries. Monitoring for signs of skin breakdown, such as erythema, blanchable or non-blanchable skin changes, and skin integrity over bony prominences, helps prevent pressure ulcers and facilitates early intervention if skin breakdown occurs. Regularly turning the client, maintaining proper positioning, and providing adequate support surfaces are essential to prevent pressure injuries.