Which nursing diagnosis is appropriate for a patient who has received a sedative-hypnotic agent?
A. Alteration in tissue perfusion
B. Fluid volume excess
C. Risk for injury
D. Risk for infection
Correct Answer: C. Risk for injury
Sedative-hypnotics cause CNS depression, putting the patient at risk for injury. Symptoms of barbiturate toxicity vary from case to case, but commonly include difficulty thinking, decreased level of consciousness, bradycardia or rapid and weak pulse, poor coordination, vertigo, nausea, muscle weakness, thirst, oliguria, decreased temperature, and dilated or contracted pupils.
Option A: The client may be at risk for altered tissue perfusion, but it is not a higher priority than being at risk for injury. Patient history should focus on determining the exact type and amount of medication taken and whether there has been co-ingestion of other substances.
Option B: Pulmonary edema is another complication associated with barbiturate toxicity and contributing to respiratory depression and death. Complications include hypotension, coma, and respiratory depression. It is important to maintain respiratory and cardiovascular status, as failure to do so can result in hypoxic brain injury and death.
Option D: Physical examination should include serial mental status, vital signs, and neurologic examinations conducted at regular intervals. Barbiturates also have been associated with thrombocytopenia and pulmonary eosinophilia (with febarbamate).
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