QLexNursing

⚫The client is exhibiting multiple signs of acute sepsis and respiratory compromise, which includes hypoxia (SpO₂ 85%), tachypnea, confusion, hypotension, and blood-tinged sputum along with a consolidated chest X-ray.

⚫These findings indicate rapid deterioration, requiring immediate and aggressive interventions to stabilize the client.

• ✅ Prepare for possible intubation and mechanical ventilation
• The client’s severe hypoxia and altered mental status indicate potential respiratory failure.
• Preparing for intubation is essential to protect the airway and ensure adequate oxygenation and ventilation, aligning with ABC (Airway, Breathing, Circulation) priorities.
• ✅ Monitor the client's blood glucose levels frequently
• Clients with sepsis are prone to hyperglycemia due to stress and may also be on glucocorticoids.
• Tight glucose control is necessary because uncontrolled blood glucose can worsen infection risk and impair immune function, thus delaying recovery.
• ✅ D. Administer IV antibiotics as prescribed
• The cornerstone of sepsis treatment is the prompt administration of broad-spectrum IV antibiotics, which must be initiated within the first hour to improve survival rates. Delay in antibiotics is directly associated with increased mortality.
• ✅ Ensure strict hand hygiene before and after client contact
• Infection control is critical in septic clients, particularly to prevent cross-contamination and protect immunocompromised individuals.
• Strict hand hygiene is a first-line defense and is mandatory before and after any patient interaction.
• ✅ Prepare to assist with a chest tube insertion
• The consolidation and blood-tinged sputum could suggest pleural effusion or empyema.
• In such cases, the provider may insert a chest tube to drain fluid or pus, relieve respiratory distress, and allow lung re-expansion.
• The nurse must be ready to assist and manage chest drainage systems.