Question

The client comes to the emergency department with a severely infected pressure ulcer on the back. The client is in septic shock. The physician orders norepinephrine (Levophed) IV. Prioritize the nursing interventions for this client.

1. Connect the client to a cardiac monitor and pulse oximeter.
2. Assess the client's blood pressure.
3. Prepare for debridement of the pressure ulcer.
4. Administer oxygen.
5. Maintain a patient airway.

Answer 1

The nursing interventions for a client with a severely infected pressure ulcer and septic shock should prioritize maintaining an airway, administering oxygen, monitoring cardiac function and blood pressure, and lastly, preparing for debridement of the pressure ulcer. These steps are essential in treating septic shock and preventing organ failure.

Step-by-step explanation:

When prioritizing nursing interventions for a client who comes in with a severely infected pressure ulcer and is in septic shock, the most urgent need is to stabilize the client's vital functions and treat the shock. With the order of norepinephrine (Levophed) IV, the following priorities should be set:

1. Maintain a patient airway. This is the most critical intervention, as septic shock can compromise the respiratory system, and an open airway is essential for life.
2. Administer oxygen. To address hypoxia, oxygen is necessary since septic shock may reduce the oxygenation of tissues.
3. Connect the client to a cardiac monitor and pulse oximeter. Monitoring the heart rhythm and oxygen saturation allows for rapid detection of life-threatening changes.
4. Assess the client's blood pressure. Blood pressure measurements are crucial to evaluate the effectiveness of vasopressor therapy and guide further treatment interventions.
5. Prepare for debridement of the pressure ulcer. Debridement is important to remove necrotic tissue and aid healing but is not as immediately life-saving as the interventions listed above.

These interventions are designed to prevent further deterioration and help treat the underlying condition causing the shock. Close monitoring and responsive medical care are crucial during the treatment of septic shock, as the condition can rapidly progress to multiple organ failure and death.