What are the immediate nursing actions for a 25-week gestation infant with tachypnea (respiratory rate 80 breaths/min), tachycardia (heart rate 180 bpm), oxygen saturation of 92%, hyperthermia (temperature 100.7°F or 38.2°C), and hypotension (mean blood pressure 27 mmHg), who is intubated and showing signs of distress, including retractions and red skin coloration?

Immediate Nursing Actions for 25-Week Gestation Infant in Distress

IMMEDIATE ASSESSMENTS (Perform NOW)

Temperature Management - PRIORITY

• Document exact axillary temperature and immediately reduce incubator/radiant warmer temperature 1
• Target temperature: 36.5°C-37.5°C (current 38.2°C indicates hyperthermia) 1
• Check incubator temperature setting and bed temperature probe placement 1
• Assess for signs of sepsis (hyperthermia is a red flag in preterm infants) 1

Respiratory Assessment

• Document exact work of breathing: severity of retractions (intercostal, subcostal, suprasternal), nasal flaring, grunting 1
• Verify endotracheal tube position and patency immediately 1
• Assess chest rise symmetry and auscultate breath sounds bilaterally 2
• Document current ventilator settings and blood gas values if available 1

Cardiovascular Assessment

• Verify mean arterial pressure measurement (27 mmHg is borderline low for 25-week infant) 3
• Assess perfusion: capillary refill time (<3 seconds normal), skin color, extremity temperature 2
• Document heart rate pattern and rhythm (180 bpm is tachycardic) 3
• Check for differential pulse oximetry between upper and lower extremities to rule out ductal-dependent cardiac lesions 4

Sepsis Evaluation

• The combination of hyperthermia, tachycardia, tachypnea, and borderline hypotension strongly suggests sepsis 1
• Obtain blood culture, complete blood count with differential, C-reactive protein NOW 1
• Document time of last feeding, abdominal examination findings (current: rounded but soft) 2
• Assess for skin lesions, umbilical cord appearance 2

IMMEDIATE INTERVENTIONS

Temperature Correction

• Reduce environmental temperature immediately to 23°C-25°C 1
• Remove excess blankets/coverings 1
• Do NOT use rapid cooling methods; gradual reduction preferred 1
• Recheck temperature every 15-30 minutes until normalized 1

Respiratory Support Optimization

• Ensure adequate PEEP is maintained (critical for preterm lung recruitment) 1
• Verify oxygen saturation target 90-95% for 25-week infant 1
• Suction endotracheal tube ONLY if secretions are obstructing airway 1
• Position infant supine with head in neutral "sniffing" position 1

Hemodynamic Support

• Establish or verify IV access immediately 4
• Prepare for fluid bolus (10 mL/kg normal saline over 30 minutes) if mean BP remains <28 mmHg 1
• Have vasopressor support ready (dopamine or dobutamine) 1

Infection Control

• Initiate broad-spectrum antibiotics within 1 hour (ampicillin + gentamicin standard for early-onset sepsis) 1
• Do NOT delay antibiotics waiting for culture results given clinical presentation 1

MONITORING FREQUENCY

Continuous Monitoring Required

• Heart rate, respiratory rate, oxygen saturation via cardiorespiratory monitor 1, 2
• Temperature probe (skin or axillary) 1

Every 15 Minutes Until Stable

• Temperature (until normalized to 36.5-37.5°C) 1
• Work of breathing assessment 1
• Perfusion assessment (capillary refill, color) 2

Every 30-60 Minutes

• Blood pressure (mean arterial pressure target >28 mmHg for 25-week infant) 3
• Ventilator settings and oxygen requirements 1

Every 2-4 Hours Once Stabilized

• Full vital sign documentation 5
• Neurological assessment (tone, activity level) 2

ESCALATE TO PHYSICIAN/NRT IMMEDIATELY IF:

• Mean arterial pressure <25 mmHg or not responding to initial fluid bolus 1, 3
• Oxygen saturation <85% despite increased support 1
• Temperature >38.5°C or <36.0°C 1
• Worsening work of breathing or decreased chest rise 1
• Decreased level of consciousness or seizure activity 2
• Differential pulse oximetry between upper/lower extremities (>3% difference) 4
• Abdominal distension, bilious aspirates, or bloody stools (necrotizing enterocolitis concern) 1
• Capillary refill >4 seconds or mottled/gray skin color 2

SAFETY CHECKS TO PREVENT COMPLICATIONS

Endotracheal Tube Security

• Verify tube position at lip marking every 2 hours 1
• Ensure tube is secured and not kinked 1
• Have reintubation equipment at bedside 1

Infection Prevention

• Strict hand hygiene before and after all patient contact 1
• Minimize handling during acute phase 1
• Ensure closed suction system if available 1

Skin Integrity

• Reposition every 2-3 hours to prevent pressure injuries (extremely fragile skin at 25 weeks) 6
• Use gel mattress or sheepskin if available 6
• Minimize adhesive use; use pectin-based barriers 6

Hypoglycemia Prevention

• Verify glucose infusion rate is adequate (minimum 4-6 mg/kg/min) 1
• Check blood glucose if not done in last 4 hours 2

Documentation

• Record all vital signs with exact times 2, 5
• Document all interventions and infant's response 2
• Note any changes in clinical status immediately 5

Equipment Readiness

• Emergency resuscitation equipment at bedside: bag-mask ventilation system, suction, emergency medications 1
• Verify alarm limits are appropriate and functioning 5

Critical Pitfall: The red skin coloration combined with hyperthermia suggests overheating from excessive environmental temperature or overbundling—this is immediately correctable but dangerous if missed, as hyperthermia increases metabolic demands and oxygen consumption in an already compromised infant 1. The clinical picture strongly suggests early sepsis requiring immediate antibiotic therapy 1.