A client is admitted to the intensive care unit (ICU) with sepsis and acute respiratory distress syndrome (ARDS). The client is orally intubated and mechanically ventilated. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

Answer:

Potential Condition:

Acute Adrenal Crisis

• The client has a history of Addison’s disease (chronic steroid use) and recent illness with vomiting, leading to decreased oral intake and medication noncompliance.
• Symptoms such as hypotension (80/50 mmHg), tachycardia (115 bpm), confusion, nausea, vomiting, and abdominal pain are classic signs of acute adrenal insufficiency.

Actions to Take:

Bolus Intravenous Fluids

• Fluid resuscitation with 0.9% normal saline is critical to restore intravascular volume and correct hypotension due to adrenal insufficiency.

Check Blood Glucose

• Hypoglycemia is a common complication of adrenal crisis due to cortisol deficiency, requiring close monitoring and possible glucose administration.

Parameters to Monitor:

Blood Pressure

• Hypotension is a hallmark of adrenal crisis and must be monitored closely to assess response to fluid resuscitation and steroid therapy.

Electrolytes

• Clients with adrenal crisis often have hyponatremia and hyperkalemia due to aldosterone deficiency, requiring frequent electrolyte monitoring.

Incorrect Choices:

Potential Conditions:

• Ketoacidosis: More common in diabetes, presents with high blood glucose and ketonuria.
• Diabetes Insipidus: Causes polyuria and dehydration but lacks hypotension and hyperkalemia.
• Myxedema: Linked to hypothyroidism, causing bradycardia and hypothermia, not hypotension and hyperkalemia.

Actions to Take:

• Hold hydrocortisone dose: Steroid replacement is necessary, not withholding it.
• Collect urine for a urinalysis: Not a priority; adrenal crisis is diagnosed via history, symptoms, and labs.
• Change intravenous fluids to 0.45%: Hypotension requires 0.9% normal saline, not hypotonic fluids.

Parameters to Monitor:

• Urine output: Useful but less critical than blood pressure and electrolytes in adrenal crisis.
• Thyroid stimulating hormone: Relevant for hypothyroidism, not adrenal insufficiency.
• Heart rate: Tachycardia is expected but is not the most critical indicator of improvement.

A. Measure the client's abdominal girth. While tracking abdominal distension is useful, it does not address the underlying cause of the client's deterioration. Measuring girth should not delay immediate intervention for a potentially life-threatening condition.
B. Monitor the client's recent hemoglobin levels. A drop in hemoglobin would indicate internal bleeding, but waiting for lab results could delay necessary treatment. The client is already showing signs of early shock, requiring urgent medical intervention rather than just monitoring.
C. Prepare for nasogastric tube (NGT) insertion. An NGT may be needed for bowel obstruction or paralytic ileus, but the client's worsening condition suggests a more urgent issue, such as intra-abdominal hemorrhage. Addressing the potential bleeding takes priority over decompression.
D. Notify the healthcare provider (HCP) of the client's status. The client's tachycardia, tachypnea, cool pale skin, and worsening abdominal distension suggest early shock, likely due to postoperative internal bleeding or abdominal compartment syndrome. Immediate notification of the HCP ensures rapid assessment, diagnostic testing, and potential emergency intervention to prevent further deterioration.