NUR 401 SEPSIS CASE STUDY

NUR 401 SEPSIS CASE STUDYI: DATA COLLECTION History of the present problem: Betty Louise is an 82- year old female who has been feeling more fatigued for the last couple days and has had a fever for the last 24 hours. She reports feeling full more often and has notices a pink tinge in her urine when she urinates. She denies dysuria but admits to an increase in urinary frequency for over a week. Her daughter brought Mrs. Betty Louise to the emergency department (ED) when her mom did not know what day it was and could not tell her if she had eaten or drank anything all day. Currently, Betty Louise is alert and has no history of dementia or confusion. Social History: Betty Louise lives at home. She is widowed and has a son and daughter who are actively involved with her on a daily basis. When her daughter, who is an RN, stopped by today, Betty Louise had a dizzy spell and fell into the side of the closet door hitting her elbow hard causing a skin tear and bleeding. She did not hit her head, only her elbow, but had to sit down because she remained dizzy. What data from the above histories is important and RELEVANT and have clinical significance to you the RN? RELEVANT Data from Present Problem: Clinical Significance:  Feeling more fatigued and having a fever for the last 24hrs  Pink tinged urine  Increase in urine frequency  Confusion with no past hx of dementia or confusion  Could indicated that the patient may have some sort of infection such as an UTI RELEVANT Data from Social History: Clinical Significance:  Dizzy spell  Skin tear and bleeding  Dizzy spells are also an indicator in older adults that an infection is present. The dizzy spells can put the patient for risk of more injuries to come. Also the skin tear can lead to another source of infection. Your text here 1 Betty Louise has the following medical history and medication reconciliation: Match the medication with the disease/diagnosis. Past Medical History: Medication Reconciliation: Type II Diabetes Mellitus Hyperlipidemia Hypertension-Essential Gout 1. Allopurinol 100 mg bid 2. Colchicine 0.6 mg prn 3. ASA 81 mg daily 4. Pioglitazone (Actos) 15 mg daily 5. Simvastatin 20 mg qHS 6. Metoprolol 25 mg bid 7. Lisinopril 10 mg daily 8. Furosemide (Lasix) 20 mg daily Lab/diagnostic results: Basic Metabolic Panel (BMP) Current value Is it HIGHT/LOW/NL Previous value Sodium (135-145 mEq/L) 140 NL 138 Potassium (3.5-5.0 mEq/L) 3.8 NL 3.9 Glucose (70-110 mg/dL) 184 HIGH 128 Creatinine (0.6-1.2 mg/dL) 1.5 HIGH 1.1 Complete Blood Count (CBC) WBC (4.5-11.0 mm#) 13.2 HIGH 8.8 Hgb (12-16 g/dL) 14.4 NL 14.6 Platelets (150-450x 103) 246 NL 140 Neutrophils % (42-72) 93 HIGH 68 Misc. Chemistries Lactate (0.5-2.2 mmol/L) 3.2 HIGH n/a What labs are RELEVANT that must be recognized as clinically significant to you the RN? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable  Glucose  Because the patient is diabetic therefore its important to  Worsening  Creatinine  WBC/neutrophil s  Lactate manage glucose so other complications don’t arise  Creatinine level indicates if the kidneys are properly functioning  A rise in WBC/neutrophil s can indicate an infection is present. Increase in WBC can also inadequate inflammation  Increase in Lactate level above 2.2 could indicate cells are performing anaerobic metabolism instead of aerobic metabolism due to lack of oxygen. This can also inadequate sepsis  Worsening  Worsening  worsening Urinalysis (UA) Current High/Low/WNL? Previous value Color (yellow) Yellow WNL Yellow Clarity (clear) Cloudy WNL Clear Specific Gravity ( 1.015-1.030) 10.32 HIGH 1.010 Protein (neg) 2+ HIGH 1+ Glucose (neg) Neg WNL Neg Ketones (neg) Neg WNL Neg Bilirubin (neg) Neg WNL Neg Blood (neg) Neg WNL Neg Nitrites Pos HIGH Pos LET(Leukocyte Esterase) (neg) Pos HIGH Pos