Patient Data

The client has not been seen in the clinic for several months and did not follow up after having annual laboratory testing done nine months ago as requested by the healthcare provider (HCP).

Which factor(s) is/are the most important for the nurse to include in an initial assessment of the client? Select all that apply.

A. An increased heart rate is a key physiological indicator of pain in infants. Following surgery, such as a pyloromyotomy, infants may not be able to verbalize discomfort, so tachycardia serves as an early warning sign of distress. Continuous monitoring of heart rate helps the nurse assess the severity of pain and the effectiveness of analgesic interventions.

B. An increased respiratory rate is another important physiological sign of pain in infants. Pain stimulates the sympathetic nervous system, leading to faster breathing. Observing tachypnea alongside other indicators provides a more comprehensive assessment of the infant’s discomfort.

C. Clenched fists are a common behavioral cue in infants experiencing pain. Nonverbal behaviors, including facial grimacing, body tension, and hand clenching, are essential for nurses to recognize because infants cannot communicate their pain verbally. These behaviors guide timely administration of analgesics and comfort measures.

D. An increased temperature is generally not a reliable indicator of pain in infants. While fever can indicate infection or inflammation, it does not correlate directly with post-surgical pain and should prompt investigation for other causes rather than serving as a pain marker.

E. Peripheral pallor of the skin may occur due to sympathetic nervous system activation in response to pain. Vasoconstriction causes the skin to appear pale, which is an observable cue that complements other physiological and behavioral indicators of discomfort.

F. Restlessness or increased irritability is a behavioral sign of pain in infants. Changes in activity level, inconsolable crying, or increased agitation often signal that the infant is experiencing discomfort and may need pharmacologic or nonpharmacologic interventions.

Rationale for Correct Choices
• Guillain-Barré syndrome: The client exhibits ascending symmetric weakness, areflexia in lower extremities, recent Campylobacter jejuni infection, and intact sensation, which are hallmark signs of Guillain-Barré syndrome (GBS), an acute autoimmune demyelinating disorder of the peripheral nervous system.
• Educate on disease progression: Informing the client about expected progression, potential complications, and signs requiring urgent attention (e.g., respiratory difficulty) reduces anxiety and promotes early reporting of worsening symptoms.
• Prepare client for intubation: GBS can rapidly progress to involve respiratory muscles; early preparation ensures timely intervention if respiratory compromise occurs.
• Neurological status: Monitoring for progression of weakness, sensory changes, and reflex loss helps assess disease severity and response to interventions.
• Respiratory function: Vital to detect early respiratory failure; includes monitoring oxygen saturation, tidal volume, and signs of respiratory distress.

Rationale for Incorrect Choices
• Sepsis: Client is afebrile, hemodynamically stable, and shows no signs of systemic infection; sepsis is unlikely.
• Polio: Polio is rare in countries with vaccination programs, and the client’s presentation follows infection with Campylobacter, not poliovirus.
• Muscular dystrophy: Progressive, chronic weakness from birth or early childhood differs from acute, post-infectious onset.
• Implement safety measures to prevent falls: While helpful, the priority in acute GBS is monitoring for respiratory compromise and disease progression.
• Initiate droplet precautions: GBS is not contagious; isolation is unnecessary.
• Educate client on genetic testing: GBS is acquired and autoimmune; genetic testing is irrelevant.
• Intake and output: No renal or fluid balance issues reported; not a primary monitoring parameter.
• White blood cells (WBC): No evidence of infection requiring WBC monitoring.
• Level of consciousness (LOC): Client is alert and oriented; GBS does not typically affect LOC.