Fundamental Reasoning: STUDENT

Sepsis
I. Developing Nurse Thinking by Identifying Clinical Relevance/Significance
History of Present Problem:
Jean Kelly is an 82 year old woman who has been feeling more fatigued for the last three days and has had a fever the
last twenty-four hours. She reports painful, burning sensation when she urinates as well as frequency of urination the last
week. It has been >90 degrees this past week. She usually drinks 2-3 glasses of liquid a day and a cup of tea. Her daughter
became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is
mentally alert with no history of confusion.

Personal/Social History:
Jean lives independently in a senior apartment retirement community. She is widowed and has two daughters who are
active and involved in her life. While taking her bath today, she was unable to get out of the tub and used the help button.
When help arrived, she was able to get to the side of the tub and sit. Upon standing to ambulate she became dizzy and lost
her balance. She didn’t get injured while coming down hard on the toilet seat.

What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
82 y/o female possible UTI
states feeling "more fatigued for the last 3 impaired LOC and mental state
days" risk for infection
fever for 24 hr
burning sensation during urination
confusion
RELEVANT Data from Social History: Clinical Significance:
independently in a senior apartment Did infection occur because she is unable to care for herself? If so
has two daughters who are active in her life
unable to get out of bathtub today than an assisted living facility may be best suited
dizzy and lost balance

Lab/diagnostic Results:
Basic Metabolic Panel (BMP): Current: High/Low/WNL?
Sodium (135-145 mEq/L) 140 WNL
Potassium (3.5-5.0 mEq/L) 3.8 WNL
Glucose (70-110 mg/dL) 184 HIGH
Creatinine (0.6-1.2 mg/dL) 1.5 HIGH
Complete Blood Count (CBC): Current: High/Low/WNL?
WBC (4.5-11.0 mm 3) 13.2 HIGH
Hgb (12-16 g/dL) 14.4 WNL
Platelets(150-450x 103/µl) 246 WNL
Neutrophil % (42-72) 93 HIGH

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Lab(s): Clinical Significance:
WB increased means infection
neutrophils
glucose hyperglycemia
creatinine kidney failure

© 2013 Keith Rischer/www.KeithRN.com

II. Nurse Collected Clinical Data:
Current VS: WILDA Pain Scale (5th VS)
T: 101.8 (oral) Words: Ache
P: 110 (regular) Intensity: 5/10
R: 24 Location: Right flank
BP: 102/50 Duration: Continuous/ongoing
O2 sat: 98% Aggreviate: Nothing
room air Alleviate: Nothing

The nurse recognizes the need to validate his/her concern of fluid volume deficit and performs a set of
orthostatic VS and obtains the following:
Position: HR: BP:
Lying 110 102/50
Standing 132 92/42

What VS data is RELEVANT that must be recognized as clinically significant?

RELEVANT VS Data: Clinical Significance:
lying HR: 110, BP: 102/50 HPO
standing HR: 132, BP: 92/42 Tachycardia

Current Assessment:
GENERAL Resting comfortably, appears in no acute distress
APPEARANCE:
RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular-S1S2, pulses strong, equal with
palpation at radial/pedal/post-tibial landmarks
NEURO: Alert and oriented x2-is not consistently oriented to date and place, c/o dizziness when she
sits up
GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants
GU: Admits to dysuria and frequency of urination the past week, right flank tenderness to gentle
palpation
SKIN: Skin integrity intact

What assessment data is RELEVANT that must be recognized as clinically significant?

RELEVANT Assessment Data: Clinical Significance:
A/o x 2 UTI symptoms
dysuria
urination 1x a week Infection
right flank tenderness when
palpating

© 2013 Keith Rischer/www.KeithRN.com

III. Developing Nurse Thinking by APPLICATION of the Applied Sciences
Fluid & Electrolytes:
Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required:
WBC possible infection UTI
Infection in body
Value: Critical value:
14.2

Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required:

Neutrophils possible infection make sure to use sterile process with patient to
not further cause infection
Value: Critical value:
no catheters or make sure they are clean
93%

Pharmacology:
Home Med: Classification: Mechanism of Action: Nursing Considerations:
Allopurinol
antigout inhibits uric acid production and monitor for wheezing, dyspnea,
(Zyloprim)
xanthine oxidase and tightness in chest

Pioglitazone
antidiabetic decreases insulin resistance eat with meal, check blood sugars,
(Actos)
don't skip dose

Simvastatin
(Zocor) antiviral inhibits HCV NS3/4A protease Daily labs

Metoprolol
Beta blocker inhibits beta 1 receptors blurred vision, HPO, bradcardia, n/v
(Lopressor)

Lisinopril
(Prinivil) ACE inhibitor inhibits angiotensin HPO, do not take during
pregnancy, swollen face, HA

© 2013 Keith Rischer/www.KeithRN.com

Medication Dosage Calculation:
Medication/Dose: Mechanism of Action: Volume/time frame to Nursing Assessment/Considerations:
Safely Administer:
Ceftriaxone cephalosporin take prescription exactly as ordered
1g IVPB
Hourly rate IVPB: take pt medical hx of any allergies
to penicillin
Normal Range: 30
(high/low/avg?)

IV. Developing Nurse Thinking by Identifying Clinical RELATIONSHIPS

1. What is the RELATIONSHIP of the past medical history and current medications?
(Which medication treats which condition? Draw lines to connect)
Past Medical History(PMH): Home Meds:
Diabetes type II 1.Allopurinol 100 mg bid
4 Gout
Hyperlipidemia 2.Colchicine 0.6 mg prn
5 IDK
HTN 3.ASA 81 mg daily
6,7,8
Gout 4.Pioglitazone (Actos) 15 mg daily
1,2 DM
5.Simvastatin 20 mg daily
6.Metoprolol 25 mg bid
HTN
7.Lisinopril 10 mg daily
8. Furosemide (Lasix) 20 mg daily

2. Is there a RELATIONSHIP between any disease in PMH that may have contributed to the development of the
current problem? (Which disease likely developed FIRST that then began a “domino effect”?)
PMH: What Came FIRST:
Diabetes type II
HTN first, then DM, hyperlipidemia, gout
Hyperlipidemia
HTN What Then Followed:
Gout

3. Is there a RELATIONSHIP of a problem in your patient’s PMH that contributed to the current primary problem?
Primary Contributing Problem: Pathophysiology Cause/Relationship to Present Problem:
DM increased urination
82 y/o increased risk for infection, mental state, ability to care for
herself

4. What is the RELATIONSHIP between the primary care provider’s orders and primary problem?
Care Provider Orders: How it Will Resolve Primary Problem/Nursing Priority:
Establish peripheral IV
a patent IV is a priority

0.9% NS 1000 mL IV bolus fluid balance

© 2013 Keith Rischer/www.KeithRN.com

 fever and pain reducer
Acetaminophen 650 mg po

Ab to treat infection
Ceftriaxone 1g IVPB…after blood/urine
cultures obtained

Morphine 2 mg IV push every 2 hours pain mgmt

prn-pain

V. Developing Nurse Thinking by Identifying Clinical PRIORITIES

5. What is the primary problem that your patient is most likely presenting with?
UTI that has not been treated resulting in altered LOC
6. What nursing priority will guide your plan of care?
treat infection and pain, risk for sepsis,

7. What interventions will you initiate based on this priority?

Nursing Interventions: Need a patent IV
Fluids-NS Rationale: Expected Outcome:
Admin Acetaminophin
admin Ceftriaxone
admin morphine

Need a patent IV fluids! IV needed for tx

Fluids-NS fluid balance after
Admin Acetaminophin fever and pain reducer polyuria
admin Ceftriaxone Ab tx for infection reduce body temp
admin morphine pain mgmt no further
complication by
infection

VI. Caring & the “Art” of Nursing

9. What is the patient likely experiencing/feeling right now in this situation?
Pain, which will be alleviated with morphine, confused mental state and not sure why she is there,
which will get resolved once infection is under control

10. What can I do to engage myself with this patient’s experience, and show that he/she matters to me as a person?
Be there for the pt even if her LOC is altered, listen to her needs

© 2013 Keith Rischer/www.KeithRN.com