Six hours into sepsis bundle, the nurse reassesses fluid status and tissue perfusion. Which actions and findings indicate appropriate post-bundle reassessment? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Hour-6 sepsis reassessment: trend lactate (clearance over 10-20 percent suggests adequate resuscitation), reassess fluid responsiveness with dynamic methods (passive leg raise raises preload transiently, stroke volume variation on arterial line, IVC ultrasound) — STATIC measures like CVP perform poorly. Re-evaluate antibiotics based on culture results and consider source control (drainage, debridement). Continue tissue-perfusion monitoring (mottling, capillary refill, MAP, urine). ROUTINE additional 30 mL/kg bolus is INCORRECT — fluid administration must be guided by responsiveness; over-resuscitation worsens outcomes.