A patient with a suspected abdominal abscess and foreign body is being prepared for surgical intervention. Which nursing intervention is the most critical to implement prior to surgery to prevent complications?

A) Administer prescribed broad-spectrum antibiotics.

B) Position the patient in a semi-Fowler's position.

C) Encourage the patient to take deep breaths and cough.

D) Provide the patient with oral fluids to maintain hydration.

A patient presents with signs of acute abdominal distress, including a distended abdomen, marked tenderness, and hypoactive bowel sounds. Laboratory results show an elevated white blood cell count and elevated inflammatory markers. An abdominal CT scan reveals an encapsulated fluid collection consistent with an abscess and a possible foreign object. Which nursing action is the most appropriate to prioritize at this time?

B) Initiate intravenous fluid therapy and monitor vital signs

A) Administer oral antibiotics as ordered

B) Initiate intravenous fluid therapy and monitor vital signs

C) Prepare the patient for immediate surgical intervention

D) Encourage the patient to ambulate to relieve abdominal distention

A patient in a high-acuity unit demonstrates worsening signs of sepsis six hours after starting broad-spectrum antibiotics. The patient's fever has increased, heart rate is elevated, blood pressure is trending downward, lactate levels are high, and blood cultures show gram-positive cocci. Despite antibiotic therapy, the patient's condition is deteriorating. What should be the nurse's priority intervention at this time?

B) Prepare the patient for immediate surgical intervention.

A) Administer an additional dose of broad-spectrum antibiotics.

B) Prepare the patient for immediate surgical intervention.

C) Increase the rate of intravenous fluids to manage hypotension.

D) Apply cooling measures to reduce the patient's fever.

A patient in a higher acuity unit is experiencing worsening sepsis despite initial antibiotic treatment. Her vital signs indicate fever, tachycardia, hypotension, and elevated respiratory rate. Her lactate level is also increased, and blood cultures show gram-positive cocci. Imaging reveals an enlarging abscess and possible bowel obstruction. Based on these findings, what is the nurse’s priority intervention to address the patient's condition?

B) Prepare the patient for surgical intervention to achieve source control.

A) Increase the rate of intravenous fluids to improve blood pressure and tissue perfusion.

B) Prepare the patient for surgical intervention to achieve source control.

C) Administer a higher dose of broad-spectrum antibiotics to combat the infection.

D) Apply continuous oxygen therapy to maintain oxygen saturation above 95%.

A patient scheduled for surgery is showing signs of septic shock with a significant drop in blood pressure, increased heart rate, and metabolic acidosis. What is the nurse's priority intervention to optimize the patient's hemodynamic status before surgery?

A) Administer high-flow oxygen to maintain oxygen saturation

C) Prepare the patient for immediate surgical intervention

D) Administer antibiotics to treat the underlying infection

A patient with severe sepsis is experiencing a progression towards septic shock, as indicated by hypotension, tachycardia, and altered mental status. The healthcare team initiates aggressive fluid resuscitation and vasopressor therapy to stabilize the patient. What is the primary goal of starting vasopressor therapy in this clinical scenario?

C) To maintain adequate mean arterial pressure

B) To improve cardiac contractility

C) To maintain adequate mean arterial pressure

D) To reduce systemic vascular resistance

A 56-year-old patient with sepsis is scheduled for surgery. Her blood pressure is 88/55 mmHg, heart rate is 140 beats per minute, and oxygen saturation is 88% despite high-flow oxygen. Laboratory results show a pH of 7.28 and lactate of 6.0 mmol/L. Which intervention should the nurse prioritize to stabilize the patient before surgery?

A) Administer a rapid fluid bolus of isotonic crystalloid

B) Increase the rate of norepinephrine infusion

C) Apply a non-rebreather mask to improve oxygenation

D) Prepare for immediate intubation and mechanical ventilation

A patient in the preoperative setting is exhibiting signs of severe sepsis with hypotension, tachycardia, cool and clammy skin, and altered mental status. The healthcare team initiated norepinephrine to support her blood pressure. What is the most critical nursing assessment to perform after starting this medication?

A) Monitor for signs of allergic reaction

B) Measure blood glucose levels

D) Evaluate for peripheral edema

A patient with suspected ARDS secondary to sepsis is displaying worsening respiratory acidosis despite initial treatment. Which intervention should the nurse anticipate to effectively manage the patient's deteriorating respiratory status?

B) Prepare for intubation and initiation of mechanical ventilation.

A) Increase the rate of the current oxygen delivery system.

B) Prepare for intubation and initiation of mechanical ventilation.

C) Administer a bronchodilator to improve airway clearance.

D) Increase intravenous fluid administration to improve perfusion.

A patient in the ICU with suspected ARDS and sepsis is showing signs of respiratory compromise. Her arterial blood gas analysis indicates respiratory acidosis, and her oxygen saturation is critically low. The team is considering intubation and mechanical ventilation. Which of the following interventions should the nurse prioritize while preparing for intubation to address the patient's respiratory needs?

C) Prepare for intubation by ensuring the availability of all necessary equipment and medications.

A) Increase the rate of norepinephrine infusion to improve hemodynamic stability.

B) Administer a high-flow nasal cannula to increase oxygen delivery.

C) Prepare for intubation by ensuring the availability of all necessary equipment and medications.

D) Encourage the patient to perform incentive spirometry to improve lung expansion.

surgically retained item - Nursing Case Study

Pathophysiology

• Primary mechanism: Surgically retained items (SRIs), such as sponges or instruments, trigger a foreign body reaction, where the immune system identifies the item as foreign and attempts to isolate it through inflammation and fibrous encapsulation.

• Secondary mechanism: The resulting inflammatory response can lead to localized infection or abscess formation, as bacteria may proliferate around the foreign material, potentially causing systemic inflammatory response syndrome (SIRS) if unchecked.

• Key complication: Persistent inflammation and infection may result in adhesions or fistulae, impairing normal organ function and potentially leading to chronic pain or bowel obstruction, necessitating further surgical intervention.

Patient Profile

Demographics:

56-year-old female, nurse

History:

• Key past medical history: Appendectomy 6 months ago, hypertension

• Current medications: Lisinopril 10 mg daily, multivitamin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Abdominal pain and fever

• Key symptoms: Increasing abdominal pain, nausea, intermittent fever, malaise

• Vital signs: Temperature 101.3°F, heart rate 112 bpm, blood pressure 138/92 mmHg, respiratory rate 22 breaths per minute

Section 1

As the clinical team proceeds with the initial assessment, they note that the patient exhibits signs of acute abdominal distress. Physical examination reveals a distended abdomen with marked tenderness, particularly in the lower quadrants, and a palpable mass suggesting an underlying abscess or encapsulated foreign body. Bowel sounds are hypoactive, indicating potential ileus or early signs of bowel obstruction. The patient’s skin is diaphoretic, and she is visibly uncomfortable, grimacing with movement.

Laboratory results further elucidate her condition: white blood cell count is elevated at 16,000/mm³, indicative of an inflammatory or infectious process. C-reactive protein and erythrocyte sedimentation rate are also elevated, supporting the diagnosis of systemic inflammation. Blood cultures are pending, but the clinical suspicion for sepsis is high given the patient's tachycardia, fever, and hypotensive trend; her blood pressure has dropped to 126/88 mmHg. Imaging studies, such as an abdominal CT scan, reveal a well-defined encapsulated fluid collection consistent with an abscess and a suspicious foreign object that could correlate with the surgically retained item from her previous appendectomy.

Given these findings, the medical team must consider the risk of complications such as sepsis or bowel obstruction. They decide to initiate broad-spectrum intravenous antibiotics while preparing for possible surgical intervention to remove the foreign body and drain the abscess. The situation requires close monitoring for any further deterioration, and the patient is transferred to a higher acuity unit for closer observation and management. The developing scenario prompts a need for continued clinical reasoning to anticipate and mitigate complications, ensuring a comprehensive approach to the patient's care.

Section 2

As the patient is closely monitored in the higher acuity unit, the clinical team observes a change in her status approximately six hours after the initiation of broad-spectrum antibiotics. The patient's fever has escalated to 39.5°C (103.1°F), and her heart rate has increased to 128 beats per minute. Her blood pressure continues to trend downward, now measuring 110/70 mmHg, indicating a progression toward septic shock. Despite the antibiotics, her condition seems to be deteriorating, suggesting that the source control has not been adequately addressed. Her respiratory rate has also risen to 24 breaths per minute, and she is now requiring supplemental oxygen to maintain an oxygen saturation of 92%.

New laboratory results further complicate the picture. The patient's lactate level has increased to 4.2 mmol/L, indicating tissue hypoperfusion and raising the concern for worsening sepsis. The blood cultures return positive for gram-positive cocci, guiding the team to adjust the antibiotic regimen to target the specific organism identified. Meanwhile, repeat imaging is ordered to reassess the size and extent of the abscess and to evaluate the positioning of the foreign object. The CT scan reveals that the abscess has slightly increased in size, and there is evidence of bowel wall thickening suggestive of an evolving bowel obstruction.

Given these findings, the team re-evaluates their plan of care. The decision is made to escalate to surgical intervention more urgently, as the patient's condition is not improving with medical management alone. The priority is to remove the foreign object and drain the abscess to achieve source control and prevent further complications. The surgical team is consulted for immediate evaluation, and preoperative preparations are initiated. The unfolding scenario emphasizes the need for dynamic clinical reasoning and timely intervention to prevent further deterioration and improve the patient's overall prognosis.

Section 3

As the surgical team prepares for intervention, the patient's condition continues to evolve. Approximately one hour before the scheduled procedure, the patient's blood pressure drops further to 95/60 mmHg, and her heart rate increases to 135 beats per minute. Her level of consciousness begins to fluctuate, with intermittent confusion and disorientation, indicating possible cerebral hypoperfusion. Her respiratory rate remains elevated at 26 breaths per minute, and she is now receiving high-flow oxygen to maintain an oxygen saturation of 90%. These changes in vital signs suggest a progression towards septic shock, necessitating immediate clinical reassessment and intervention to stabilize her before surgery.

Laboratory results reveal worsening metabolic acidosis, with an arterial blood gas showing a pH of 7.32 and a bicarbonate level of 18 mEq/L, further supporting the diagnosis of severe sepsis. Additionally, her white blood cell count has spiked to 18,000/µL, reflecting a heightened inflammatory response. The increase in lactate to 5.0 mmol/L is particularly concerning, indicating ongoing tissue hypoxia and the need for urgent source control. The team's priority is to optimize the patient's hemodynamic status preoperatively by initiating aggressive fluid resuscitation with isotonic crystalloids and administering vasopressors to support her dropping blood pressure.

Despite the clinical deterioration, the team remains focused on the importance of source control through surgical intervention. The decision is reinforced by the new diagnostic results, which underscore the urgency of removing the foreign object and addressing the abscess to prevent further complications. As the patient is prepared for the operating room, the clinical team engages in a dynamic discussion to ensure all necessary resources are in place for a successful surgical outcome. The evolving situation exemplifies the critical need for timely intervention and comprehensive clinical reasoning to navigate the complexities of sepsis management.

Section 4

As the surgical team continues to prepare for the operating room, the patient's condition takes another turn. Approximately 30 minutes before the procedure, her vital signs show further instability. Her blood pressure has now decreased to 88/55 mmHg, and her heart rate remains elevated at 140 beats per minute. The patient's skin is cool and clammy, and her capillary refill time is prolonged at over 4 seconds, indicating poor peripheral perfusion. Her level of consciousness continues to fluctuate, with more pronounced episodes of confusion and lethargy. Despite the high-flow oxygen, her oxygen saturation has dropped to 88%, suggesting worsening respiratory compromise.

In response to these changes, the clinical team conducts a rapid reassessment. New laboratory results indicate a further drop in pH to 7.28, and a rise in lactate to 6.0 mmol/L, highlighting the severity of her metabolic acidosis and tissue hypoxia. The team identifies signs of potential acute kidney injury, with a serum creatinine level rising to 2.1 mg/dL from a baseline of 0.9 mg/dL. This renal impairment is likely secondary to the ongoing hypoperfusion and sepsis, necessitating adjustments to her fluid management plan.

The priority becomes more acute as the team implements additional interventions to stabilize the patient. They decide to increase the rate of isotonic crystalloid infusion and initiate norepinephrine to better support her blood pressure. A Foley catheter is inserted to accurately monitor her urine output as an indicator of renal perfusion. The nursing team engages in continuous monitoring, ready to communicate any further deterioration. This coordinated approach underscores the importance of dynamic clinical reasoning and reinforces the critical nature of timely intervention to improve the patient's condition before surgery. The unfolding scenario illustrates the complexity of managing sepsis and the necessity for swift, informed decisions to optimize patient outcomes.

Section 5

As the clinical team continues their efforts to stabilize the patient, they closely monitor her response to the implemented interventions. After the administration of norepinephrine and increased fluid resuscitation, there is a slight improvement in her hemodynamic status. Her blood pressure rises modestly to 95/60 mmHg, and her heart rate decreases to 130 beats per minute, suggesting a partial response to the vasopressor therapy. However, her oxygen saturation remains concerning at 85%, despite further adjustments to her oxygen delivery system, prompting the team to suspect evolving pulmonary complications. The patient's respiratory rate has increased to 32 breaths per minute, and auscultation reveals diminished breath sounds at the bases bilaterally, raising suspicion for potential atelectasis or evolving acute respiratory distress syndrome (ARDS).

In light of these developments, the team orders a stat chest X-ray and arterial blood gas analysis to further evaluate her respiratory status and guide future interventions. The chest X-ray reveals bilateral infiltrates consistent with pulmonary edema, corroborating the clinical suspicion of ARDS. The arterial blood gas shows a worsening respiratory acidosis with a pH of 7.25, PaCO2 of 60 mmHg, and PaO2 of 55 mmHg. This new diagnostic information necessitates a reevaluation of her respiratory management, including the potential need for intubation and mechanical ventilation to stabilize her gas exchange and prevent further respiratory compromise.

The nursing team, in collaboration with the intensivist, discusses the implications of these findings and the necessity for advanced airway management. The evolving ARDS in the context of sepsis and likely retained surgical item poses significant challenges, emphasizing the need for vigilant monitoring and timely escalation of care. As they prepare for potential intubation, the team continues to prioritize maintaining adequate perfusion and oxygenation, while closely monitoring her renal function and other organ systems for any further signs of deterioration. This scenario underscores the interconnectedness of systemic complications and the critical role of interdisciplinary collaboration in optimizing patient outcomes in the face of complex clinical challenges.