A nurse is providing discharge teaching for the family of a client who had a tracheostomy inserted 2 months ago. Which of the following instructions should the nurse include?

Rationale:

• Temperature 37° C (98.6° F): The client's temperature has remained stable at 37° C from Day 1 to Day 3. Although it is within normal range, the lack of change means it does not reflect any clinical improvement or deterioration in condition.
• Blood pressure 112/56 mm Hg: The systolic blood pressure has improved from 92 mm Hg to 112 mm Hg, suggesting improved perfusion. Although diastolic pressure is unchanged, this rise indicates partial stabilization of cardiovascular status after initial hypotension.
• Heart rate 88/min: The heart rate decreased from 118/min on Day 1 to 88/min on Day 3, indicating reduced sympathetic response. This suggests that blood volume and hemodynamic status have improved, likely due to effective intervention for blood loss.
• Respiratory rate 20/min: A drop from 24/min to 20/min reflects improvement in respiratory effort. The normalization of respiratory rate indicates reduced metabolic demand and improved oxygen delivery after stabilization.
• Oxygen saturation 95% on room air: The client’s oxygen saturation improved from 92% to 95%, returning to normal range. This shows better oxygenation, likely related to improved circulatory status and reduced bleeding or hypovolemia.
• Hemoglobin 15 g/dL: Hemoglobin increased from 7 g/dL to 15 g/dL, returning to normal. This significant rise indicates successful treatment of anemia, likely through blood transfusion, and improved oxygen-carrying capacity.
• Hematocrit 45%: Hematocrit rose from 24% to 45%, matching the hemoglobin improvement. This suggests the client’s volume status and red blood cell concentration have normalized, reflecting effective management of acute blood loss.
• Platelets 100,000/mm³: The platelet count decreased from 120,000/mm³ to 100,000/mm³, remaining below the normal range. This decline may reflect worsening liver dysfunction or ongoing coagulopathy, and does not indicate clinical improvement.
• Albumin 3.0 g/dL: Albumin remained unchanged at 3.0 g/dL and is below the normal range of 3.5–5 g/dL. This reflects persistent impaired liver synthetic function and ongoing risk for complications like ascites and delayed healing.
• Ammonia 160 mcg/dL: Ammonia levels increased from 150 to 160 mcg/dL, indicating worsening hepatic detoxification. This elevated level increases the client’s risk for hepatic encephalopathy and does not signify recovery.

Rationale:
A. Hypotension: Circulatory overload typically causes hypertension rather than hypotension due to increased blood volume and pressure. Hypotension would be more consistent with a different transfusion reaction such as anaphylaxis or septic shock.

B. Flattened jugular veins: Jugular vein distention, not flattening, is a classic sign of circulatory overload. Distended neck veins indicate elevated central venous pressure from fluid excess.

C. Lethargy: While lethargy may occur with various conditions, it is not a specific or early sign of circulatory overload. More immediate symptoms include respiratory distress and cardiovascular changes.

D. Bounding pulse: A bounding pulse is a key sign of circulatory overload, reflecting increased stroke volume and elevated intravascular volume. It often occurs alongside hypertension, dyspnea, and jugular vein distention, especially in older adults with compromised cardiac function.