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Original Question

Report from Night Nurse at 7am: Mr. Robert Hipp is a 77y/o male who is POD 3 from a right hip replacement. He has a history of hypertension, no other comorbidities. -Patient has a R subclavian triple lumen central line. D5 .45 is running at 80 ml/hr through the purple port. -Dressing over hip is C/D/I, no strikethrough -His oxygen saturation dropped to 88% while he was sleeping last night, so he was started on 2L per nasal cannula at 0200. Lungs clear but diminished at bases. He coughed a bit in his sleep -Foley present, 200cc output overnight, emptied at 0600 -Patient was neurologically intact last evening and has slept through the night -Patient has not requested pain meds overnight. He last received Norco at 5pm yesterday. -General diet -4am vitals: HR 90 RR 20 BP 116/54 Temp 99.2F -NKDA Medication list Carvedilol 12.5mg BID Hydrochlorothiazide 12.5mg daily Hydrocodone bitartrate and acetaminophen 5mg/325mg q4h PRN Docusate 100mg daily Heparin 5000U subq daily Your initial assessment of patient at 8am Vital Signs – BP 112/70 (Low) – P 92, regular – RR 26 – T 101.7 F, oral (little bit high) – O2 sat 90% on 2L per NC Skin – Warm, diaphoretic – R hip incision covered with dressing that is C/D/I, no strikethrough Lungs/Thorax – Increased rate and (+) dyspnea. Absent lung sounds in bases. Cardiac – RRR, normal S1 and S2, no S3 or S4 Abd – Flat, soft, multiple heparin injection bruises – BS x 4 GU – Foley intact – 15cc of urine in bag at 0800, cloudy with sediment MS/Ext – (-) cyanosis, clubbing, edema – Pulses 4+, bounding Neuro – Patient difficult to arouse, had to shout and shake patient to get him to open his eyes – Oriented to self only; states that it is December of 2016 and that he is at home – Able to follow command to lift arms only after asking 3 times Laboratory Results from draw taken at 0400 Na 139 mEq/L WBC 25,000 /mm3 K 3.9 mEq/L PT 10 sec Cl 100 mEq/L PTT 93 sec BUN 29 mg/dL Hgb 14.5 g/dL Cr 1.7 mg/dL Hct 41 % Glucose 159 mg/dL After reporting findings to the nurse practitioner on the ortho team, further labs are obtained at 0830. Results: Lactate 3.9 mEq/L CRP 5.7 mg/dl D-dimer 328 mcg/L Protein C 29% Covid PCR – negative ABGs pH 7.31 pO2 86 PCO2 41 HCO3 17 Case Study Questions 1. What are the patient’s risk factors for sepsis? What potential sources/sites of infection are present? 2. For each of the patient’s prescribed medications, provide the class, mechanism of action, side effects, nursing considerations, and the reason that this patient is taking the medication. 3. For each abnormal lab value and vital sign, provide the normal value and a rationale for why there is an abnormal value for this patient. Be very detailed in explaining WHY the lab value or vital sign is abnormal for THIS patient – provide pathophysiologic basis for abnormalities and the clinical significance. 4. What other physical assessment findings are concerning? Explain the pathophysiologic reason for the abnormal assessment findings and the clinical significance. 5. Calculate the patient’s qSOFA score. 6. Why is the patient not tachycardic? 7. Explain whether or not the patient fits the criteria for the following: a. Systemic Inflammatory Response Syndrome b. Sepsis c. Severe sepsis d. Hypotension, sepsis induced e. Septic shock 8. What would you expect the treatment to be for this patient?

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