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Sepsis Case Study Analysis Sepsis Day 1 – 9 am – An elderly female who is transported from a local nursing home to the Emergency Department for evaluation of fever, confusion, and cloudy urine is admitted to a medical unit. • ER Report – This is an 85-year-old female from a local nursing home. She came in by ambulance because she was getting more and more confused. Her medical diagnosis is probable urosepsis. We drew electrolytes, BUN, creatinine, CBC, PT/PTT and did a urinalysis with C&S and CXR. We placed a 20-gauge angiocath in her right hand and she has D5NS with KCl 20 mEq/L at 125 cc/hr. She has an 18 Fr foley that is draining cloudy dark amber urine. She has a past history of CVA and hypertension. Her nursing home meds include HCTZ 50 mg q am, Colace 50 mg po qd, ASA 81 mg qd, K-dur 20 mEq po qd, Plavix 75 mg po qd, Prevacid 60 mg po qd. Her vital signs are 110/60, pulse 110, respirations 24, temperature 100.1 F, O2 Sat 92% on 2 L/min nasal cannula and she is in NSR. She was just discharged last week after having pneumonia and her old chart says she has NKDA, is 5’1″, and weighs 95 lb. She looks at you when you call her name, but we cannot understand her when she tries to talk. Her right side is weaker than her left, but she does grip to command with her left hand. Her breath sounds are clear but diminished in the bases. She has good bowel sounds. She has an undated tegaderm on her coccyx Admission Orders • Admit medical service with dx of probable urosepsis • BR c BRP • VS q 4 hr • O2 2 L/min nasal cannula • Soft diet • Identify and continue home meds • Blood cultures x2 then start Cefotaxime 1 gm IVPB q 12 hr. • Tylenol gr. X po for temperature > 101 F • I & O • Change foley upon arrival to floor and place to gravity • D51/2NS with KCl 20 mEq/L at 125 cc/hr • Electrolytes, BUN, creatinine in am Diagnostics • Na 155 mEq/L • Cl 112 mEq/L • K 3.2 mEq/L • BUN 45 mg/dl • Cr 0.8 mg/dl • Hgb 12g/dl • Hct 40% • WBC 12,000/mm3 • Platelets 150,000/ mm3 • PT 12.3 sec • PTT 60 sec • CO2 30 mEq/L CXR – No active disease Urinalysis • Appearance – cloudy SG – 1.030 • Glucose – neg • Color – amber • Nitrites – neg • WBC – 7 • RBC — none • Odor – foul • Ketones – neg • pH – 8.4 • Crystals – neg • Protein – none • Casts — none Day 2 – Medical Unit, 9 am – During her first day on the medical unit all her admission orders have been implemented including blood cultures, antibiotics, and new foley. Nursing Assessment – Opens eyes to hearing name called, does not follow commands with extremities but moves left arm and leg spontaneously, moans but does not use intelligible words. PERL. Breath sounds equal with crackles throughout. O2 sat 88% on 2 L/min NC. Respiratory rate 30. Heart tones with S1, S2, and irregular rhythm. Apical rate is 120. Right radial pulse is 112. Blood pressure right arm 100/60. Temperature 97.6 axillary. Bilateral radial and dorsalis pedis pulses palpable. Abdomen soft flat non-tender with diminished bowel sounds. D51/2NS with KCl 20 mEq/L at 125 cc/hr stopped for infiltrated IV—IV dc’d. Foley to gravity draining cloudy yellow urine. Not alert enough to swallow. No family present currently. 24 hr I/O – 3200/1000. Instructions 1. Components of critical thinking Identify assumptions Identify data inconsistencies in the case Cluster related data according to either 1) body systems or 2) Gordon’s Functional Health Patterns Identify missing data Identify conclusions 2. Most significant pathological process Etiology Pathology Clinical manifestations Diagnostic tests Provide a rationale for abnormal lab data 3. Identify 5 priority nursing/collaborative diagnoses with the expected outcome (goal statement) Nursing diagnostic statements must be written correctly Outcome (goal) statements must be measurable, realistic, and include a time frame 4. Identify priority interventions for each diagnosis Include the rationale for each intervention (identify why this intervention is necessary for the care of this patient)

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