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Difficulty: Very hardPhysiological Adaptation

An older adult client is admitted with a severe urinary tract infection. Over the past hour, the client has become restless and confused. Current vital signs are: blood pressure 84/52 mm Hg84/52\text{ mm Hg}, heart rate 128 bpm128\text{ bpm}, respiratory rate 30 breaths/min30\text{ breaths/min}, and temperature 101.8∘F101.8^\circ\text{F} (38.8∘C38.8^\circ\text{C}). Oxygen saturation is 93%93\% on room air. An arterial blood gas (ABG) and serum lactate analysis reveal the following:

ParameterValue
pH\text{pH}7.527.52
PaCO2\text{PaCO}_226 mm Hg26\text{ mm Hg}
HCO3−\text{HCO}_3^-21 mEq/L21\text{ mEq/L}
PaO2\text{PaO}_274 mm Hg74\text{ mm Hg}
Lactate\text{Lactate}4.3 mmol/L4.3\text{ mmol/L}

Which of the following prescribed interventions should the nurse prioritize?

  1. A
    Commence a continuous intravenous infusion of norepinephrine.
  2. B
    Administer intravenous sodium bicarbonate to buffer the elevated lactate level.
  3. Initiate a rapid intravenous infusion of 0.9%0.9\% sodium chloride at 30 mL/kg30\text{ mL/kg}.Answer
  4. D
    Administer an intravenous sedative to manage agitation and decrease the respiratory rate.

Answer

The nurse should prioritize initiating a rapid intravenous fluid bolus of 0.9% sodium chloride.
The client is exhibiting classic signs of early septic shock: severe hypotension, tachycardia, altered mental status, and an elevated lactate level. In the initial stages of sepsis, systemic vasodilation and increased capillary permeability cause profound relative hypovolemia. According to evidence-based sepsis management guidelines, the absolute priority is aggressive fluid resuscitation (typically a 30 mL/kg bolus of isotonic crystalloid) to restore intravascular volume, increase cardiac output, and improve tissue perfusion.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The combination of infection, hypotension, tachycardia, altered mental status, and elevated lactate indicates early septic shock.
Recognizing the shock state dictates the urgency and sequence of interventions.
2
Interpret the arterial blood gas (ABG) results.
The pH is 7.52 (alkalemia) and PaCO2 is 26 mm Hg (respiratory alkalosis).
The client is hyperventilating in response to fever and early tissue hypoxia, creating a primary respiratory alkalosis despite the rising lactate level.
3
Determine the priority physiological need.
The client's profound relative hypovolemia from sepsis-induced vasodilation must be corrected immediately.
Without adequate intravascular volume, tissue perfusion cannot be restored, and secondary interventions like vasopressors will fail.
4
Select the most appropriate intervention.
Administering a 30 mL/kg isotonic crystalloid fluid bolus is the required first-line action.
Clinical guidelines mandate aggressive fluid resuscitation before the use of vasopressors in septic shock.

Key Concept

Early recognition and fluid resuscitation sequence in septic shock
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Topics

Physiological Adaptation

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