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Difficulty: HardPharmacological and Parenteral Therapies

A rapid response team transfers an adult client with severe sepsis to the critical care unit. The client has a newly established multilumen central venous catheter (CVC) and is receiving a continuous intravenous (IV) infusion of norepinephrine. To safely manage this pharmacological therapy and the client's hemodynamic status, which interventions should the nurse implement? (Select all that apply.)

  1. Titrate the continuous infusion rate to maintain a mean arterial pressure (MAP) of at least 65 mm Hg.Answer
  2. Evaluate the client's distal extremities frequently for changes in capillary refill, pulse quality, and skin temperature.Answer
  3. C
    Conclude that a decrease in urine output to 15 mL/hr is an expected, therapeutic effect of the medication's profound vasoconstrictive properties.
  4. D
    Administer prescribed intermittent intravenous (IV) antibiotics directly into the norepinephrine infusion port to ensure rapid systemic delivery.
  5. Monitor the client's electrocardiogram (ECG) continuously for the development of medication-induced tachyarrhythmias.Answer
  6. F
    Place the client immediately into a high Fowler's position if the systolic blood pressure drops abruptly to 75 mm Hg.

Answer

The correct interventions are titrating the infusion to maintain a MAP of at least 65 mm Hg, evaluating distal extremities for adequate perfusion, and continuously monitoring the ECG for tachyarrhythmias.
Norepinephrine is a potent alpha- and beta-adrenergic agonist used in distributive shock to increase systemic vascular resistance and cardiac output. The therapeutic goal is to maintain a mean arterial pressure (MAP) of 65 mm Hg or greater to ensure adequate perfusion of vital organs. Because of its potent vasoconstrictive effects, peripheral ischemia is a significant risk, necessitating frequent evaluation of capillary refill, pulses, and skin temperature. Additionally, its beta-1 stimulating properties increase myocardial oxygen demand and the risk of potentially life-threatening tachyarrhythmias, making continuous ECG monitoring essential.

Step-by-Step Solution

1
Identify the primary therapeutic goal of the norepinephrine infusion.
The goal is to increase systemic vascular resistance and cardiac output.
Maintaining a MAP of at least 65 mm Hg is the established standard to ensure blood flow reaches vital organs during distributive shock states.
2
Assess potential adverse physiological effects of the pharmacological therapy.
Norepinephrine's alpha-1 and beta-1 agonism causes intense peripheral vasoconstriction and cardiac stimulation.
This necessitates frequent monitoring of peripheral extremities for ischemia and continuous ECG monitoring for tachyarrhythmias to prevent severe complications.
3
Evaluate the incorrect interventions against principles of safe parenteral therapy and shock management.
Decreased urine output, unverified IV co-administration, and high Fowler's positioning are identified as unsafe or incorrect.
Inadequate urine output indicates worsening shock. Co-administration of IV meds requires compatibility verification to prevent precipitation or bolusing of the pressor. High Fowler's positioning exacerbates hypotension by reducing venous return.

Key Concept

Safe administration, hemodynamic targeting, and continuous monitoring of vasoactive parenteral therapies in the critically ill client.
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Topics

Pharmacological and Parenteral Therapies

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