# A patient receiving norepinephrine (Levophed) infusion for septic shock requires continuous monitoring. Which assessment finding would be the nurse's highest priority to report immediately to the healthcare provider?

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## 문제

A patient receiving norepinephrine (Levophed) infusion for septic shock requires continuous monitoring. Which assessment finding would be the nurse's highest priority to report immediately to the healthcare provider?

The nurse is caring for a patient with septic shock who is receiving norepinephrine infusion at 15 mcg/min through a central venous catheter.

## 보기

1. Blanching and coolness of the fingers and toes with delayed capillary refill **✔ 정답**
2. Blood pressure increase from 85/50 mmHg to 110/70 mmHg
3. Heart rate increase from 95 bpm to 105 bpm
4. Urine output of 35 mL in the past hour

**정답: 1**

## 해설

Blanching and coolness indicate severe peripheral vasoconstriction from norepinephrine, risking tissue necrosis and requiring immediate action. Other findings (BP increase, HR increase, urine output) are expected or less critical.

## 심화 해설

Clinical Context

In septic shock, profound vasodilation and increased capillary permeability lead to maldistribution of blood flow and relative hypovolemia. Norepinephrine is the first-line vasopressor recommended to restore perfusion pressure through potent alpha-1 adrenergic agonism, which causes arterial and venous vasoconstriction [1]. While the goal is to achieve a mean arterial pressure (MAP) of at least 65 mmHg to maintain organ perfusion, this vasoconstriction is not selective and can significantly reduce blood flow to non-vital tissue beds, particularly the skin and distal extremities.

Priority Assessment: Peripheral Ischemia

The finding of blanching and coolness of the fingers and toes with delayed capillary refill is the highest priority to report. This clinical picture represents severe peripheral vasoconstriction and hypoperfusion that has progressed beyond the expected pharmacologic effect of the drug. While some degree of cool extremities is anticipated with norepinephrine, the presence of blanching and a markedly delayed capillary refill time signals a critical imbalance between vasopressor-driven vasoconstriction and tissue oxygen delivery. This can be a precursor to digital ischemia and necrosis if the dose is not titrated or the strategy reassessed.

The rationale for its prioritization is grounded in the principles of multimodal assessment during resuscitation. Current evidence emphasizes that resuscitation is not guided by a single parameter but by integrating multiple markers of perfusion, including capillary refill time [1]. An abnormally prolonged capillary refill time is a validated indicator of poor tissue perfusion and has been shown to be a relevant target for therapy titration, with outcomes equivalent to protocolized, goal-directed strategies [1]. A finding of extreme peripheral vasoconstriction is a direct signal that the current resuscitation strategy may be causing harm and requires immediate modification.

Analysis of Other Options

- **Option 2:** A blood pressure increase from 85/50 mmHg to 110/70 mmHg is a desired therapeutic response, indicating that the norepinephrine is effectively increasing systemic vascular resistance and perfusion pressure. This is an expected and positive finding that would be documented but not urgently reported.

- **Option 3:** A heart rate increase from 95 bpm to 105 bpm is a mild sinus tachycardia. This is an anticipated compensatory response and a common, less concerning effect of norepinephrine's beta-1 adrenergic activity. It requires monitoring but is not the immediate priority over evidence of end-organ tissue ischemia.

- **Option 4:** A urine output of 35 mL in the past hour is below the target of 0.5 mL/kg/hr for an average adult, indicating oliguria and potential acute kidney injury. This is a critical sign of renal hypoperfusion. However, it is a downstream, cumulative indicator of the shock state over the past hour. The immediate, real-time evidence of severe peripheral tissue ischemia (blanching, delayed capillary refill) signals an active, iatrogenic component of the problem that can be acted upon instantly by adjusting the vasopressor dose, making it the higher priority for immediate reporting.

References (research sources)

- [1]Resuscitation Targets, Fluids, and Vasoactives in Septic Shock.Research articleGraham JD, Lanspa MJ, Peltan ID. (2026) · DOI: 10.1016/j.ccm.2025.10.003

## 임상 시나리오

Norepinephrine & Peripheral Ischemia MonitoringEarly Recognition of Limb-Threatening Vasoconstriction
While some coolness of extremities is expected with norepinephrine, the combination of blanching and a markedly delayed capillary refill time (> 3-4 seconds) signals severe, uncompensated peripheral ischemia.

This finding indicates a critical imbalance between vasopressor-driven vasoconstriction and tissue oxygen delivery, which can rapidly progress to digital necrosis if the dose is not immediately titrated down or the resuscitation strategy reassessed.

CautionDo not dismiss extremity changes as a routine side effect. Report blanching and delayed capillary refill immediately as the highest priority, as this represents an early warning sign of potential limb loss, not just a cosmetic change.

## 핵심 개념

- **Norepinephrine** — A potent alpha-1 adrenergic agonist vasopressor used as first-line therapy in septic shock to increase systemic vascular resistance and mean arterial pressure.
- **Peripheral Ischemia** — A state of inadequate blood flow to the extremities, a serious adverse effect of high-dose vasopressors, manifesting as blanching, coolness, and delayed capillary refill.
- **Capillary Refill Time** — A clinical assessment measure of peripheral perfusion; a markedly delayed time (>3-4 seconds) indicates significant vasoconstriction or low cardiac output.
- **Mean Arterial Pressure (MAP)** — The average arterial pressure during a single cardiac cycle, with a target of at least 65 mmHg in septic shock resuscitation to ensure organ perfusion.

## 같은 주제 문제

- [A nurse is caring for a patient receiving norepinephrine (Levophed) infusion for septic sh…](https://mymerci.kr/pages/nclex_q.php?qn_id=543516)

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