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Difficulty: MediumPhysiological Adaptation

A nurse is caring for an older adult client who is receiving intravenous antibiotics for complicated pyelonephritis. During the mid-shift assessment, the client is restless and mildly confused. The nurse obtains the following vital signs:

ParameterCurrent ValueAdmission Baseline
Temperature37.2°C (99.0°F)37.0°C (98.6°F)
Heart Rate114 beats/min82 beats/min
Respiratory Rate24 breaths/min16 breaths/min
Blood Pressure104/84 mm Hg132/78 mm Hg

Which of the following actions is the priority for the nurse to implement?

  1. A
    Document the confusion as an expected age-related cognitive change and dim the room lights.
  2. Notify the healthcare provider immediately and prepare to administer an isotonic intravenous fluid bolus.Answer
  3. C
    Continue routine monitoring and reassess the client's vital signs in one hour.
  4. D
    Assign the unlicensed assistive personnel to reassess the client's blood pressure manually.

Answer

The priority action is to notify the healthcare provider immediately and prepare to administer an isotonic intravenous fluid bolus.
The client is exhibiting classic signs of early, compensatory septic shock resulting from their systemic infection. These signs include a dramatically narrowing pulse pressure (the difference between systolic and diastolic pressure is only 20 mm Hg), tachycardia, tachypnea, and new-onset altered mental status (restlessness and confusion). Immediate medical intervention, typically beginning with rapid isotonic fluid resuscitation, is required to prevent progression to uncompensated shock.

Step-by-Step Solution

1
Analyze the client's current vital signs compared to the admission baseline.
The client has developed significant tachycardia (114 beats/min), tachypnea (24 breaths/min), and a markedly narrowed pulse pressure (decreased from a baseline of 54 mm Hg down to 20 mm Hg).
Identifying subtle hemodynamic changes is critical for the early detection of life-threatening complications.
2
Correlate the physical assessment findings with the vital signs and underlying diagnosis.
The new-onset restlessness and confusion, combined with the concerning vital sign trends in a client with a severe systemic infection (pyelonephritis), strongly indicate inadequate cerebral and systemic tissue perfusion.
Altered mental status is frequently the earliest sign of hypoxia or decreased perfusion, particularly in the older adult population.
3
Determine the clinical priority based on the assessment data.
The client is in the early (compensatory) stage of septic shock and requires immediate medical intervention.
Prompt isotonic fluid resuscitation is necessary to restore intravascular volume, improve cardiac output, and prevent the progression to irreversible multi-organ failure.

Key Concept

Early Recognition and Management of Compensatory Septic Shock
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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