The nurse is administering low dose dopamine to a client who is in septic shock. Which physiologic parameter should the nurse use to evaluate a therapeutic response to the dopamine?

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. Temperature. While temperature monitoring is important in septic shock to assess infection control, it is not an indicator of dopamine's effectiveness. Dopamine primarily affects renal perfusion and blood pressure, not body temperature regulation.
B. Heart sounds. Dopamine is a vasopressor and inotropic agent, but it does not directly impact heart sounds. While it can increase myocardial contractility, assessing blood pressure and perfusion parameters is more relevant in evaluating its therapeutic effects.
C. Urinary output. Low-dose dopamine (1-5 mcg/kg/min) primarily acts as a dopaminergic agonist, increasing renal blood flow and urine output by dilating renal arteries. In septic shock, maintaining adequate kidney perfusion is critical to prevent acute kidney injury (AKI). A therapeutic response to dopamine would be seen as improved urinary output (≥ 30 mL/hr), indicating effective renal perfusion.
D. Pupil response. Dopamine does not directly affect pupil size or reactivity. Pupil assessment is more relevant in neurological evaluations, not in monitoring the effects of dopamine in septic shock.