The nurse caring for a client with sepsis documents a diagnosis of 'alteration in comfort related to chills and hyperpyrexia.' Which independent intervention should be included in the plan of care?

The nurse caring for a client with sepsis documents a diagnosis of 'alteration in comfort related to chills and hyperpyrexia.' Which independent intervention should be included in the plan of care?

• A. Place a hyperthermia blanket on the client.
• B. Assess the client's vital signs every 2 hours.
• C. Obtain blood sputum cultures.
• D. Administer an antipyretic medication every 4 hours.

Answer: (B)

When someone with sepsis is experiencing fever and chills, the most important independent action is to monitor the patient closely by checking vital signs regularly. Frequent vital signs give real-time insight into the patient’s current status—temperature trend, heart rate, blood pressure, respiratory rate, and oxygen saturation—and help detect early signs of deterioration, guiding timely escalation of care and adjustments in treatment. Choosing a measure that would add heat to the patient would worsen fever and metabolic demand, so a hyperthermia blanket isn’t appropriate. Obtaining sputum cultures is valuable for diagnosis but isn’t an independent action addressing comfort or immediate stability; it requires clinician orders and doesn’t directly impact the patient’s current state. Administering an antipyretic may be needed, but it depends on orders and careful consideration of timing and patient condition, whereas ongoing vital signs assessment is within the nurse’s independent scope and directly supports safe, responsive care in this scenario.

When someone with sepsis is experiencing fever and chills, the most important independent action is to monitor the patient closely by checking vital signs regularly. Frequent vital signs give real-time insight into the patient’s current status—temperature trend, heart rate, blood pressure, respiratory rate, and oxygen saturation—and help detect early signs of deterioration, guiding timely escalation of care and adjustments in treatment.

Choosing a measure that would add heat to the patient would worsen fever and metabolic demand, so a hyperthermia blanket isn’t appropriate. Obtaining sputum cultures is valuable for diagnosis but isn’t an independent action addressing comfort or immediate stability; it requires clinician orders and doesn’t directly impact the patient’s current state. Administering an antipyretic may be needed, but it depends on orders and careful consideration of timing and patient condition, whereas ongoing vital signs assessment is within the nurse’s independent scope and directly supports safe, responsive care in this scenario.