Case studies: Documentation of sepsis Review the sepsis simulation and complete a head to toe assessment and the related interventions including...

Question Answered step-by-step Case studies:Documentation of sepsis Review the sepsis simulation and complete a head to toe assessment and the related interventions including medications James Daniel date of birth January 17, 1986. No known drug allergies came in around 0400 with complaints of fatigue, fever and malaise for the past three weeks says. His temperature has ranged between 101 to 104 in the past week. Temps on admission was around 100.2 orally. He has been taking acetaminophen and Ibuprofen every four to six hours at home and things that it is help a little. Vitals are okay otherwise only past medical history is the hypertension and Raymond’s disease. No past surgical history or met at home. Labs are okay, so NP wrote DC orders or just waiting for his ride to arrive.Question from physician: Mr. Daniels I see you haven’t had any medications since you’ve been here. What was the last time you had Acetaminophen or Ibuprofen? Answer from Mr. Daniels: Just before I left to come here around four hours ago maybe. Physician: I am going to do an assessment to se how you’re doing right nowMr. Daniels’s blood pressure: 113/80Temp: 101Pulse ox 95%Heart rate: 110Respiratory rate: 18No painBut Mr. Daniels does not have any energy at all. He feels like he wants to sleep all the time. Question from Physician: What is your usual blood pressure? The night nurse said that you had prehypertension. Answer from Mr. Daniels: I think the top number is usually 130 or 140, I guess. I am not sure. I had hope when I came here, they were going to help me, but I guess it they think I’m okay to go home I’ll sleep better in my own bed. Th physician was concern because Mr. Daniels Temp is 101 his tachycardic. WBCs are normal but the high Temp and high heart rate are indicating of sepsis. It is unsafe to send him home without ruling out the systemic bacterial infection.Mr. Daniels set up to avoid and said he felt like he might pass out.The nurse starts him on tele and start a liter of normal saline bolus and blood pressure every 5 minutes.They have sinus tach and BP at 96/72Temp: 102.5Saline via right antecubital 20-gauge started at 1519.Order: Lactate, CBC chem seven, blood culture and ABG at 1519 The nurse started blood gas and lactate of 7 and PH of 7.2 on the Ice dadThe nurse starts a second liter of normal saline bolus, try for an 18 gauge in his right arm.Nurse stars a gram Vancomycin after the get blood culture.Order: Lactate of 7, PH 7.2 to another normal saline bolus and second access and one gram Vancomycin ordered at 15 26. Health Science Science Nursing NURS 450 Share QuestionEmailCopy link Comments (0)