The nurse is caring for a patient on the night shift in respiratory distress due to influenza. Over the last few hours, the patient has become increasingly confused, perfusion has decreased, and urine output has fallen to zero. The nurse contacts the resident physician to come assess the patient and requests an order for transfer to the intensive care unit. The physician orders the nurse to administer 1L 0.9% NaCl via IV infusion. One hour after the infusion is complete, the patient has made no improvement. What is the nurse’s next action?

Question

The nurse is caring for a patient on the night shift in respiratory distress due to influenza. Over the last few hours, the patient has become increasingly confused, perfusion has decreased, and urine output has fallen to zero. The nurse contacts the resident physician to come assess the patient and requests an order for transfer to the intensive care unit. The physician orders the nurse to administer 1L 0.9% NaCl via IV infusion. One hour after the infusion is complete, the patient has made no improvement. What is the nurse&rsquo;s next action?

Accepted Answer

Contact the resident. The patient is exhibiting signs of shock. The nurse&rsquo;s first action is to contact the resident once more to discuss the patient&rsquo;s lack of improvement and request an escalation of care. If the resident does not provide this, the nurse escalates through the chain of command to page the attending physician. If the patient deteriorates further, a rapid response may be necessary. Involving the charge nurse can be helpful for support but is not necessary.

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