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P.S., a 76-year-old woman, was brought to the emergency department (ED) by ambulance after her husband found her sitting on the side of the bed, awake but nonverbal. She has a history of chronic atrial fibrillation, osteoarthritis, and hypertension. Her current medications include diltiazem, carvedilol, and dabigatran. Upon arrival to the ED, she was sent for a STAT CT scan, then evaluated by the Stroke Team nurse. Her initial vital signs include BP 110/60, P 158, R 20, T 100.8° F (38.2° C). She weighs 198 pounds (90 kg).

 

1. Name at least two risk factors P.S. has that led to the evaluation for a stroke.

 

2. What other things will you ask about when completing the history?

 

CASE STUDY PROGRESS

The CT scan results were normal, and the NIHSS Stroke score was rated as zero. The ED physician orders lab work, which has been drawn. P.S. asks to use the bedpan, and her urine was noted to be dark orange, cloudy, with a strong odor. You perform a point of care urinalysis and, suspecting a urinary tract infection (UTI), sends a specimen for culture and sensitivity. A second set of vital signs are recorded: BP 98/58, P 164, R 18, T 101.6° F (38.7° C).

 

Chart View

Laboratory Test Values

Sodium 150 mEq/L (150 mmol/L)
Potassium 4.8 mEq/L (4.8 mmol/L)
Chloride 100 mEq/L (100 mmol/L)
CO2 25 mEq/L (25 mmol/L)
Glucose 104 mg/dL (5.8 mmol/L)
BUN 10 mg/dL (3.6 mmol/L)
Creatinine 1.2 mg/dL (106 mcmol/L)
Lactic acid 3.2 mg/dL (3.6 mmol/L)
WBC 18.6 1000/mm3 (18.6 x 109/L)
Hgb 14 g/dL (140 g/L)
Hct 40.9%
Platelet 211,000 /mm3 (211 x 109/L)

3. Which laboratory results concern you and why?

 

4. The ED physician suspects that P.S. has sepsis. Explain sepsis.

 

5. After reviewing P.S.’s assessment, which findings reflect positive SIRS criteria? Select all that apply.

a. Elevated pulseb. Elevated temperaturec. Elevated sodium leveld. Decreased blood pressuree. Elevated white blood cell count

 

6. Do any of P.S.’s assessment findings indicate organ dysfunction? Provide rationale.

 

 

CASE STUDY PROGRESS

Based on the possible urinary tract infection, positive SIRS criteria and elevated lactic acid level, P.S. is diagnosed with severe sepsis. The physician gives new orders for ceftriaxone 1 gram every 12 hours IVPB; blood cultures × 2; lactic acid every 4 hours × 2; IV bolus of Normal Saline (NS), 30 mL/kg; and O2 at 2 L per nasal cannula. She is to be transferred to the progressive care unit.

7. Will you administer the ceftriaxone first, or obtain the lab work first? Provide rationale for your choice.

 

 

8. Calculate the dose of the IV NS bolus.

 

 

9. What is the purpose of the fluid bolus?

 

CASE STUDY PROGRESS

P.S. is transferred to the progressive care unit. Current vital signs are BP 108/72; P 148; R 18; T 100.4° F (38° C). P.S. seems more alert and is asking what has happened. When told that she is in the hospital, she states, “I don’t even remember getting here!” You explain to P.S. that she is receiving antibiotics for a serious infection and ask P.S. how long her urine had looked dark and cloudy. P.S. replied, “It’s been a week or so. I just didn’t want to bother anyone.”

 

10. The nurse discusses with P.S. the importance of reporting the signs and symptoms of a UTI and reviews the importance of proper perineal hygiene. Which statement by P.S. indicates that she understands instructions?

a. “If I think I have a urine infection, I will start an antihistamine.”b. “If I drink enough cranberry juice, I won’t get any urine infections.”c. “I will be sure to wipe from back to front when I use the bathroom.”d. “If I think I’m getting another infection, I will call my doctor right away.”

 

11. Which tasks are appropriate to assign to the UAP assisting you with P.S.’s care? Select all that apply.

a. Take vital signs.b. Assist P.S. to walk to the bathroom.c. Assess P.S.’s lung and heart sounds.d. Provide teaching about her sepsis diagnosis.e. Attach P.S. to portable telemetry monitoring.

 

 

CASE STUDY PROGRESS

P.S.’s second lactic acid level results are 2.8 mg/dL (3.1 mmol/L), and her vital signs are BP 118/72, P 136, R 18, T 100.2° F (37.9° C). She is awake, alert, and asking for dinner.

12. Interpret her lactic acid level. What does the result indicate?

 

 

13. P.S. will stay in the progressive care unit for another 24 hours, then will be transferred to a medical/telemetry unit before she is discharged. During this time, what is your priority action?

 

CASE STUDY P.S., a 76-year-old woman, was brought to the emergency department (ED) by ambulance after her husband found her sitting on the side of the bed, awake but nonverbal. She has a history of chronic atrial fibrillation, osteoarthritis, and hypertension. Her current medications include diltiazem, carvedilol, and dabigatran. Upon arrival to the ED, she was sent for a STAT CT scan, then evaluated by the Stroke Team nurse. Her initial vital signs include BP 110/60, P 158, R 20, T 100.8° F (38.2° C). She weighs 198 pounds (90 kg).

1. Name at least two risk factors P.S. has that led to the evaluation for a stroke.

 

2. What other things will you ask about when completing the history?

 

CASE STUDY PROGRESS

The CT scan results were normal, and the NIHSS Stroke score was rated as zero. The ED physician orders lab work, which has been drawn. P.S. asks to use the bedpan, and her urine was noted to be dark orange, cloudy, with a strong odor. You perform a point of care urinalysis and, suspecting a urinary tract infection (UTI), sends a specimen for culture and sensitivity. A second set of vital signs are recorded: BP 98/58, P 164, R 18, T 101.6° F (38.7° C).

Chart View

Laboratory Test Values

Sodium 150 mEq/L (150 mmol/L)
Potassium 4.8 mEq/L (4.8 mmol/L)
Chloride 100 mEq/L (100 mmol/L)
CO2 25 mEq/L (25 mmol/L)
Glucose 104 mg/dL (5.8 mmol/L)
BUN 10 mg/dL (3.6 mmol/L)
Creatinine 1.2 mg/dL (106 mcmol/L)
Lactic acid 3.2 mg/dL (3.6 mmol/L)
WBC 18.6 1000/mm3 (18.6 x 109/L)
Hgb 14 g/dL (140 g/L)
Hct 40.9%
Platelet 211,000 /mm3 (211 x 109/L)

3. Which laboratory results concern you and why?

 

4. The ED physician suspects that P.S. has sepsis. Explain sepsis.

 

5. After reviewing P.S.’s assessment, which findings reflect positive SIRS criteria? Select all that apply.

a. Elevated pulseb. Elevated temperaturec. Elevated sodium leveld. Decreased blood pressuree. Elevated white blood cell count

 

6. Do any of P.S.’s assessment findings indicate organ dysfunction? Provide rationale.

 

 

CASE STUDY PROGRESS

Based on the possible urinary tract infection, positive SIRS criteria and elevated lactic acid level, P.S. is diagnosed with severe sepsis. The physician gives new orders for ceftriaxone 1 gram every 12 hours IVPB; blood cultures × 2; lactic acid every 4 hours × 2; IV bolus of Normal Saline (NS), 30 mL/kg; and O2 at 2 L per nasal cannula. She is to be transferred to the progressive care unit.

7. Will you administer the ceftriaxone first, or obtain the lab work first? Provide rationale for your choice.

 

 

8. Calculate the dose of the IV NS bolus.

 

 

9. What is the purpose of the fluid bolus?

 

CASE STUDY PROGRESS

P.S. is transferred to the progressive care unit. Current vital signs are BP 108/72; P 148; R 18; T 100.4° F (38° C). P.S. seems more alert and is asking what has happened. When told that she is in the hospital, she states, “I don’t even remember getting here!” You explain to P.S. that she is receiving antibiotics for a serious infection and ask P.S. how long her urine had looked dark and cloudy. P.S. replied, “It’s been a week or so. I just didn’t want to bother anyone.”

10. The nurse discusses with P.S. the importance of reporting the signs and symptoms of a UTI and reviews the importance of proper perineal hygiene. Which statement by P.S. indicates that she understands instructions?

a. “If I think I have a urine infection, I will start an antihistamine.”b. “If I drink enough cranberry juice, I won’t get any urine infections.”c. “I will be sure to wipe from back to front when I use the bathroom.”d. “If I think I’m getting another infection, I will call my doctor right away.”

 

11. Which tasks are appropriate to assign to the UAP assisting you with P.S.’s care? Select all that apply.

a. Take vital signs.b. Assist P.S. to walk to the bathroom.c. Assess P.S.’s lung and heart sounds.d. Provide teaching about her sepsis diagnosis.e. Attach P.S. to portable telemetry monitoring.

 

 

CASE STUDY PROGRESS

P.S.’s second lactic acid level results are 2.8 mg/dL (3.1 mmol/L), and her vital signs are BP 118/72, P 136, R 18, T 100.2° F (37.9° C). She is awake, alert, and asking for dinner.

12. Interpret her lactic acid level. What does the result indicate?

 

 

13. P.S. will stay in the progressive care unit for another 24 hours, then will be transferred to a medical/telemetry unit before she is discharged. During this time, what is your priority action?

 

CASE STUDY OUTCOME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
NURSING 210

 

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