A 56 year-old admitted to ICU 2

A 56 year-old admitted to ICU 2 days for Respiratory failure and their history is hypertension, coronary artery disease, Atrial filbrillation, and heart failure. The client has an oral ETT with ventilatory settings FiO2 50%, AC 18, tidal volume 450, Peep 5; responds to painful stimuli with facial grimmace, RASS -4, propofol and versed drips, CPOT -2. Lungs coarse rhonchi in RLL and suctioning thick yellow secretions, heart irregular, cardiac rhythm strip listed below, abd distended with hypoactive bowel sounds, radial pulses 1+, skin warm, dry, cap refill >3 sec, pedal pulses 1+ with cool skin,urine output 30ml for last 4 hours per foley, VS: 98/50 (66), 120, 22, pulse ox 93% on FiO2 50%, temp 37.6 (99.6). Which priority clinical findings should the nurse report to the phyician? Select all that apply. 1. Thick yellow sputum secretions 2. urine output 30 ml for last 4 hours 3. The client’s BP, HR, and RR 98/50 (66), 120, 22 have triggered the Sepsis alert. 4. Abdomen distended and hypoactive bowel sounds 5. RASS -4, propofol and versed drips, CPOT -2. SCIENCE HEALTH SCIENCE NURSING NURS 2444

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