A nurse on an inpatient mental health unit is admitting a client

Exhibits

The nurse is reviewing the client's medical record at 0830 on day 2 of admission.

For each finding, click to specify whether the finding indicates a potential improvement in or a potential worsening of the client's condition.

Blurred vision:

Indicates Potential Worsening: Blurred vision is a common side effect of lithium toxicity, which the client has based on the elevated lithium level of 1.9 mEq/L (normal is less than 1.5 mEq/L). It is considered a potential worsening sign, as it suggests the client's lithium levels may be too high, leading to side effects like visual disturbances.

Blood pressure:

Indicates Potential Improvement: The blood pressure is relatively stable, with a slight drop from 114/64 mm Hg (Day 1) to 98/56 mm Hg (Day 2). While there is a decrease, it is still within a normal range, indicating no immediate concern. It is important to monitor blood pressure, but a small decrease can be expected in some cases, especially in the context of medication or rest.

Urine amount and color:

Indicates Potential Improvement: The client reports voiding a large amount of dilute yellow urine. This is a positive sign, as it indicates that the kidneys are functioning properly and that the client is adequately hydrated. The color and volume of urine are both normal and suggest no issues with fluid balance or kidney function.

Lithium level:

Indicates Potential Worsening: A lithium level of 1.9 mEq/L is above the therapeutic range of less than

1.5 mEq/L and indicates lithium toxicity. This is a worsening sign, as elevated lithium levels can lead to symptoms such as nausea, tremors, uncoordinated gait, and blurred vision (all of which are present in this client). The nurse should prioritize addressing this issue to prevent further complications.

Gait when ambulating:

Indicates Potential Worsening: The client is noted to have an uncoordinated gait, which is another sign of lithium toxicity. Incoordination and tremors are common signs of lithium toxicity, and unsteady gait can increase the risk of falls. This indicates that the client's condition may be worsening due to the elevated lithium level and the associated side effects.