Patient Profile:

• Age: 68 years
• Gender: Male
• Medical History: Hypertension, Type 2 Diabetes Mellitus
• Medications: Lisinopril, Metformin
• Allergies: None

Chief Complaint: The patient presents to the emergency department (ED) with sudden onset of right-sided weakness and difficulty speaking that began approximately 1 hour prior to arrival.

Exhibits

Choose three parameters the nurse should monitor to assess the patient's progress.

Choice A reason: Amber fluid is typically a sign of serous exudate, which is a normal part of the inflammatory process and wound healing. It indicates the body's immune response to the injury and is generally not a cause for concern unless the volume significantly increases or changes in appearance.

Choice B reason: Clear drainage, or serous fluid, is also a normal finding in wound healing. It indicates that the wound is exuding plasma, which helps to keep the wound moist and supports the healing process. This type of drainage is typically not worrisome unless there are other signs of infection or complications.

Choice C reason: Purulent, draining wound is a major concern as it indicates the presence of pus, which is often a sign of infection. Purulent drainage can be yellow, green, or brown and is usually thick and malodorous. The presence of pus suggests that there are bacteria or other pathogens in the wound, and immediate medical intervention is necessary to prevent further complications and promote healing.

Choice D reason: Blood-tinged fluid, or serosanguinous drainage, is common in fresh wounds or after debridement. It indicates a mixture of plasma and red blood cells and can be seen in the early stages of wound healing. While it is generally not alarming, the nurse should monitor the volume and changes in the drainage to ensure there are no signs of excessive bleeding or infection.

Choice A reason: Increased blood pressure is a common physiological response to pain. When a person experiences pain, the body's sympathetic nervous system is activated, causing an increase in heart rate and blood pressure. This response is part of the body's fight-or-flight mechanism, intended to help cope with the stressful situation.

Choice B reason: Increased respiratory rate is another sign of unrelieved pain. Pain can lead to rapid, shallow breathing as the body reacts to the discomfort. This response can help deliver more oxygen to tissues during times of stress but can also contribute to feelings of anxiety and fatigue if it continues over a prolonged period.

Choice C reason: Increased heart rate is a typical response to pain. Just like increased blood pressure, the heart rate rises as part of the body's sympathetic response to pain, which prepares the body to either confront or escape the source of pain. Monitoring heart rate can therefore provide critical information about the patient's pain levels and overall physiological state.