An 85-year-old female client was brought to the emergency department this morning by her daughter because of confusion and lethargy. The daughter reports that her mother lives with her, and over the past few weeks she has become increasingly tired, weak, and very thirsty. The daughter tells the nurse that her mother has a history of diabetes mellitus type 2 and heart failure. Home medications include metformin 500 mg in the morning with breakfast and again at dinner, 10 mg furosemide every other morning, lisinopril 2.5 mg daily, and carvedilol 3.125 mg twice daily. This morning the daughter reports that she had to help her mother to the bathroom because of her weakness. She noticed a "funny smell" to her mother's urine and thought it looked concentrated. After laboratory and diagnostic testing were completed, the client was diagnosed with hyperglycemic hyperosmolar syndrome (HHS) and urinary tract infection (UTI).
The client arrives to the medical unit and has an IV solution of 0.45% normal saline infusing at 100 mL/hr via an infusion device. The admission nurse in the medical unit reviews the notes from the ED and notes that the client received 5 units regular insulin by IV bolus and has a continuous IV insulin solution infusing at a rate of 5 units/hr. Ciprofloxacin 400 mg IV every 8 hours is prescribed. The nurse performs an admission assessment and documents the findings.
Vital signs: temperature = 101°F (38.3°C), apical heart rate = 96 beats/min and regular, respirations = 20 breaths/min, oxygen saturation = 92% on room air (RA), blood pressure = 104/68 mm Hg. Skin dry with decreased turgor. Finger stick blood glucose (FSBG) = 450 mg/dL (25 mmol/L). Client reports thirst and tolerating oral fluids without nausea. Weight = 112 lb (50.8 kg) which is a weight loss of 8 lb (3.6 kg) since 2 weeks ago. Fine crackles noted bilaterally in the lungs. Denies shortness of breath. No cyanosis; capillary refill 3 seconds. Pedal pulses 2+ bilaterally; 2+ edema bilaterally in feet and ankles; neck vein distention noted. Abdomen soft, bowel sounds present × 4, states last bowel movement yesterday (soft, brown, moderate amount). Has low abdominal discomfort on palpation; 3/10 on a 0 to 10 pain intensity scale. States she is urinating every 3 to 4 hours with no burning. Moves all extremities but is weak and needs assistance with standing and ambulating. Is alert and oriented. States no numbness or tingling in extremities; PERRLA.
1. Which client findings that require immediate follow-up by the nurse.