A critical care nurse evaluates a client with severe sepsis who is receiving a continuous intravenous infusion of norepinephrine. The client has become increasingly restless and confused over the past hour, with new-onset mottling of the lower extremities. Current assessment data include:
- Blood pressure: mm Hg
- Heart rate: beats/min
- Respiratory rate: breaths/min
- Arterial blood gas (ABG): pH , PaCO mm Hg, HCO mEq/L, PaO mm Hg
- Central venous oxygen saturation (ScvO ):
- Serum lactate: mmol/L
Based on these findings, which action should the nurse prioritize?
- Administer a rapid isotonic crystalloid fluid bolus.Cevap
- BIncrease the rate of the norepinephrine infusion to improve tissue oxygen delivery.
- CPrepare equipment for immediate endotracheal intubation and mechanical ventilation.
- DAdminister a prescribed intravenous bolus of sodium bicarbonate.
Cevap
The correct action is to administer a rapid isotonic crystalloid fluid bolus to increase cardiac output and tissue perfusion.
The clinical picture demonstrates profound, unresuscitated shock. Although the mean arterial pressure (MAP) is technically adequate (around mm Hg), the severely narrowed pulse pressure ( mm Hg), extremely low central venous oxygen saturation (ScvO of ), high lactate, and physical signs of poor perfusion (mottling, confusion) indicate that cardiac output is grossly inadequate. The blood pressure is only being maintained by extreme vasoconstriction from the norepinephrine. Administering an isotonic fluid bolus is the priority to increase intravascular volume, improve stroke volume, and enhance tissue oxygen delivery.
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Anahtar Kavram
In severe sepsis, a 'normal' mean arterial pressure achieved via high-dose vasopressors can mask profound hypoperfusion. A severely narrowed pulse pressure, low ScvO2, and elevated lactate require volume expansion to improve cardiac output, rather than further vasoconstriction.