Final answer:
The most important intervention in a sepsis protocol for a client with multi-organ failure is to Maintain strict intake and output to monitor fluid balance and adjust treatments, which is critical for managing blood pressure and organ function in septic patients.
Step-by-step explanation:
The correct option : d
When caring for a client with multi-organ failure due to sepsis from a ruptured appendix, the most important intervention for a nurse to include in the plan of care is to Maintain strict intake and output. This assessment is crucial because it helps to monitor fluid balance, avoid fluid overload, and adjust treatment plans accordingly, especially important in managing sepsis which can lead to changes in blood pressure and organ function. Additionally, maintaining strict intake and output records can assist in the detection of early signs of renal failure, a common complication of sepsis.
Since sepsis and septic shock can lead to multi-organ failure, maintaining homeostasis through careful fluid management is critical. It requires meticulous measurement of all fluids that enter and leave the body, which includes intravenous fluids, oral intake, and all forms of output such as urine, vomit, and drains. This data provides essential information to the clinical team, enabling prompt intervention should the patient's condition change.
The sepsis protocol typically includes aggressive fluid resuscitation, broad-spectrum antibiotics, and careful monitoring of vital signs and laboratory values. While other interventions such as warming extremities, raising the head of the bed, and monitoring blood glucose levels are also important in the care of the septic patient, the priority lies in managing the patient's fluid status to support blood pressure and organ perfusion.