Med Surge Rapid Respond
RAPID REASONING ACTIVITY (Sepsis)
Mr. Meyer is a 64-year-old man who has noted progressive redness and swelling of his L lower leg over the past week. The redness started in his lower leg and has now progressed up to his knee. He had been feeling more weak and not feeling well in the last 24 hours. He became concerned and came to the ED when he began to have a fever at home that started 8 hours ago as well as increasing pain in the L leg.
PMHx:
HTN
HLD
Your initial VS:
T: 102.9 (o)
P: 118
RR: 24
BP: 128/68
O2 sats: 95% on RA
Your initial nursing assessment:
GENERAL APPEARANCE: Resting comfortably. Appears tired and easily fatigued
EXTREMITIES/SKIN: Skin is cherry red from just below L leg patella, all the way down to the foot. Unilateral swelling of 1+ pitting edema in the L leg.
NEUROLOGIC: Alert and orientated x4
RESPIRATORY: Denies S OB. Breath sounds equal and with good aeration bilaterally.
CARDIAC: Pulses 3 + throughout. Heart rate S1-S2 regular
ABDOMEN/GI: Abdomen soft, nontender with active bowel sounds. No guarding or point tenderness present.
GENITOURINARY: Urine clear yellow. Frequency of urination with small voiding every 30-60 minutes.
Physician orders:
Blood cultures x2
UA/UC
Use skin marker to outline areas of redness on lower legs
Establish 2 large-bore IVs
Imipenem/Cilastatin (Primaxin) 500 mg IVPB
Lab/diagnostic results:
CBC:
Hgb: 12.9
WBC:18.8
Neutrophils: 96%
BMP:
Sodium: 138
Potassium: 3.9
Glucose: 348
Lactate: 3.9
Creatinine: 1.2
1. What is the medical problem that your patient is most likely presenting with?
2. What is the underlying cause/pathophysiology of this concern?
3. Based on the data you have collected, what is your primary concern right now?
4. What interventions will you initiate based on this primary concern? (Start with ABC priorities)
5. With body system will you most thoroughly assess based on the patient’s chief complaint and primary/priority concern? (Start with ABC body systems)
6. What is the worst possible complication to anticipate? (Start with ABC priorities)
7. What nursing assessment(s) will you need to initiate to identify and respond to quickly if this complication develops?
8. What VS and assessment data is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT VS/assessment data:
Relationship to primary medical problem:
9. What lab/diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Diagnostic results:
Relationship to primary medical problem:
10. What is the relationship between the following physician orders/meds and your patient’s primary medical problem?
PHYSICIAN ORDERS:
Blood cultures x2
UA/UC
Use skin marker to outline areas of redness on lower legs
Establish 2 large-bore IVs
Imipenem/Cilastatin (Primaxin) 500 mg IVPB
How it will help resolve primary problem (rationale)
