A nurse is assessing a patient 24 hours after abdominal surgery. Which assessment finding would be the priority concern requiring immediate intervention?

In the first 24-48 hours after major abdominal surgery, a temperature of 102.2°F (39°C) with tachycardia is a red flag for systemic inflammatory response syndrome (SIRS) or early sepsis. Conduct a full head-to-toe assessment focusing on potential infectious sources: surgical wound (erythema, drainage, dehiscence), respiratory system (crackles, diminished breath sounds suggesting atelectasis or pneumonia), urinary tract (dysuria, cloudy urine if catheterized), and intravenous access sites (phlebitis). Monitor vital signs every 1-2 hours, trending heart rate, blood pressure, respiratory rate, and oxygen saturation for signs of deterioration such as hypotension or tachypnea.

• Notify the surgical team and rapid response team if sepsis criteria are met (suspected infection plus two or more SIRS criteria with evidence of organ dysfunction).
• Obtain blood cultures from two separate sites, wound culture if drainage is present, and urine culture before initiating antimicrobial therapy.
• Administer antipyretics as ordered and initiate cooling measures (tepid sponging, cooling blanket) if temperature exceeds 39°C.
• Start intravenous fluid resuscitation with crystalloids (e.g., Lactated Ringer's or 0.9% sodium chloride) at 30 mL/kg bolus as prescribed for suspected sepsis.
• Administer broad-spectrum antibiotics within one hour of sepsis recognition, per facility protocol and surgical team orders.
• Monitor urine output hourly; oliguria (less than 0.5 mL/kg/hour) may indicate acute kidney injury from sepsis.

While infection is the primary concern, consider non-infectious causes of fever and tachycardia: pulmonary embolism (sudden onset dyspnea, pleuritic chest pain), atelectasis (common in first 48 hours, usually low-grade fever), drug reaction, or transfusion reaction. Serial lactate levels, complete blood count with differential, and C-reactive protein can help differentiate infectious from non-infectious etiologies. Reassess the patient every 15-30 minutes until stabilized, documenting response to interventions and any changes in mental status, which is an early sign of cerebral hypoperfusion in sepsis.