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Zorluk: ZorPhysiological Adaptation

A clinical unit is monitoring a client admitted for acute pyelonephritis. During the afternoon assessment, the client becomes increasingly restless and confused. The nurse reviews the most recent diagnostic and assessment data:

Assessment ParameterCurrent Value
Heart Rate122 beats/min122\text{ beats/min}
Blood Pressure88/54 mm Hg88/54\text{ mm Hg}
Temperature38.9∘C38.9^\circ\text{C} (102∘F102^\circ\text{F})
Arterial Blood pH7.307.30
PaCO2\text{PaCO}_231 mm Hg31\text{ mm Hg}
HCO3−\text{HCO}_3^-15 mEq/L15\text{ mEq/L}

Based on these clinical findings, which of the following interventions should be implemented? (Select all that apply)

  1. Initiate a rapid intravenous infusion of 0.9%0.9\% sodium chloride.Cevap
  2. Obtain blood culture samples from two different peripheral sites.Cevap
  3. C
    Administer intravenous sodium bicarbonate to rapidly correct the metabolic acidosis.
  4. D
    Place the client in a high Fowler's position with legs resting dependently.
  5. E
    Delay the administration of broad-spectrum antibiotics until specific culture results return.

Cevap

The nurse should initiate a rapid intravenous infusion of 0.9% sodium chloride and obtain blood culture samples from two different peripheral sites.
The client is demonstrating signs of early septic shock characterized by hypotension, tachycardia, fever, and metabolic acidosis (lactic acidosis due to hypoperfusion). The immediate nursing priorities are to restore intravascular volume and tissue perfusion using an isotonic crystalloid solution, and to promptly obtain blood cultures so that empirical broad-spectrum antibiotic therapy can be initiated without delay.

Adım Adım Çözüm

1
Analyze the vital signs and physical assessment findings.
The client exhibits tachycardia, hypotension, fever, and altered mental status (restlessness/confusion).
These are classic early systemic indicators of sepsis progressing to septic shock, signaling a massive systemic inflammatory response and loss of intravascular volume.
2
Interpret the arterial blood gas (ABG) values.
The ABG reveals uncompensated metabolic acidosis (low pH, low HCO3-) with partial respiratory compensation (lowered PaCO2).
In the context of infection and shock, this indicates lactic acidosis resulting from anaerobic metabolism due to severe tissue hypoperfusion.
3
Determine the highest priority physiological interventions.
The priority is to restore circulating volume with isotonic fluids and identify the pathogen.
Rapid fluid resuscitation corrects the hypoperfusion driving the lactic acidosis, and obtaining cultures immediately prepares the client for life-saving broad-spectrum antibiotics.

Anahtar Kavram

Early recognition and prioritization of interventions in septic shock, emphasizing rapid fluid resuscitation and obtaining cultures prior to antibiotic therapy.
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Physiological Adaptation

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