Question: Case Study: Sepsis Identifying Data: Name: M.M. Age: 84 Years-old Gender: Male Patient’s Story: M.M., An 84-year-old Male, Arrives At The Emergency Department (ED) With His Daughter. His Daughter Tells The Nurse, “He Hasn’t Seemed Like Himself. He Is Having Trouble Going To The Bathroom And His Urine Has A Strong Smell.” History M.M. Has A History …

Case Study: Sepsis

Identifying Data:

Name:                       M.M.

Age:               84 years-old

Gender:         Male

Patient’s Story:

M.M., an 84-year-old male, arrives at the EmergencyDepartment (ED) with his daughter. His daughter tells the nurse,“He hasn’t seemed like himself. He is having trouble going to thebathroom and his urine has a strong smell.”

History

M.M. has a history of hypertension (HTN) andhyperlipidemia; and takes an angiotensin-converting enzyme (ACE)inhibitor, a thiazide diuretic and an HMG-CoA reductase inhibitor(a statin).

The nurse takes M.M.’s vital signs.

Vital Signs:

Blood Pressure (BP):          100/60

Heart Rate (HR):                96 beats per minute (bpm)

Respiratory Rate (RR):       26 breaths perminute

SpO₂:                                              90% on room air

Temperature (T):               39 degrees Celsius

Upon further assessment, the nurse finds M.M. is weak.His skin is warm and dry. He is oriented to person and place, butstates the year is 1992.

1. Multiple-choice: Which of the following actions shouldthe nurse complete first for M.M.?

1. Elevate the head of the bead (HOB).
2. Notify the physician about M.M.’s temperature andSpO₂.
3. Apply a cool washcloth to M.M.’s forehead.
4. Apply a cardiac monitor.

The nurse updates the ED physician about M.M.’sstatus.

Physician’s Orders:

The physician orders a complete blood count (CBC), aswell as an electrolyte profile, creatinine and blood urea nitrogen(BUN), an arterial blood gas (ABG), a lactic acid and bloodcultures (X 2). He also orders a urinalysis, urine culture andchest and abdominal x-rays. Finally, he requests that nurse toapply a nasal cannula to keep M.M.’s SpO₂ > 92% andstart an intravenous (IV) line to administer 1 L NaCl 0.9% andantibiotics.

2. Ordering: In which order should the following be done?Place a number next to each.

_____ Draw blood and urinecultures.

_____ Apply nasal cannula.

_____ Start an intravenous line.

_____ Administer antibiotics.

_____ Draw complete blood count (CBC)and electrolyte profile.

Vancomycin 1 g is prepared in 250 mL of NaCL .9% by thepharmacy. The nurse will use an electronic infusion pump to deliverthis antibiotic.

3. Multi-select: Too rapid administration of intravenous(IV) vancomycin may place the patient at increased risk for whichadverse reaction? (Select-all-that-apply)

1. Nausea and vomiting.
2. Red man syndrome.
3. Superinfection.
4. Phlebitis.
5. Ototoxicity.

7. Multiple-choice: Before administering vancomycin, thenurse should be sure to assess which of the following laboratoryvalues?

1. Hemoglobin and hematocrit.
2. Prothrombin time (PT) and international normalized ratio(INR).
3. Albumin and glucose.
4. Serum creatinine and blood urea nitrogen (BUN).

While at M.M.’s bedside, the nurse notices he is moredrowsy. He is now only oriented to person. The nurse takes anotherset of vital signs.

Vital signs:

BP: 84/48

HR: 110 bpm

RR: 34 bpm

SpO₂: 88% on 2L nasal cannula

Temperature: 39.2 degrees Celsius

The nurse titrates the oxygen flow meter to 4L andupdates the ED physician. The ED physician places an arterial lineand a central line to initiate vasopressors. He orders anorepinephrine infusion to be titrated to keep the MAP > 65mmHg. He also tells the nurse to prepare to the patient fortransfer to the intensive care unit (ICU).

NOTE: Mean Arterial Pressure (MAP) is measured directlywith an arterial line; however, to calculate the MAP, the formulais MAP = (systolic BP = 2 x diastolic BP)/3. The MAP should be 60or over in order to adequately perfuse the coronary arteries,brain, and kidneys.

8. Fill-in-the-Blank. The nurse sets up the norepinephrineinfusion and a second nurse independently confirms the medication.The patient now has two peripheral intravenous (IV) sites and atriple-lumen subclavian central venous line.

1. Which IV access site(s) would be best to use for the IVadministration of norepinephrine?
2. Which IV access site(s) would not be appropriate for IVadministration of norepinephrine?

Explain your rationale.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

10. Multiple-choice: Ten minutes after the norepinephrineinfusion is initiated, M.M.’s blood pressure (BP) is 82/48 mmHg andthe mean arterial pressure (MAP) is 58 mmHg. Which action by thenurse is most appropriate?

1. Notify the physician about the BP.
2. Stop the norepinephrine infusion and request a change inmedication.
3. Increase the norepinephrine infusion.
4. Continue the infusion at the same rate.

The ICU nurse calls to tell the ED nurse that M.M.’s bedis ready. The ED nurse provides a verbal report and M.M. istransferred.