What are priority actions to be completed

Reference no: EM133398205

Case: A 72-year-old client, with a history of heart failure HF has been in the surgical critical care unit for past 2 days following abdominal surgery for stomach cancer. She has a surgical incision to her LUQ, closed with staples, but otherwise her skin is intact. She has a central line in her right IJ, and a urinary catheter putting out 50 mLs per hour. Her dobutamine was tapered off overnight. At report, the oncoming nurse learns that there is a new order to discontinue the central line and urinary catheter today, and the physical therapist is coming to evaluate the client. The oncoming nurse also learns that the client has been alert and oriented x4, on room air, and her vitals have been within normal limits.

At your morning assessment of the client, her vitals are BP 95/65; HR 115; RR 20; and temperature 100.4°F. The client is visibly flushed and clammy to the touch. She is alert and oriented x3, and following commands. Her urinary catheter is putting out 40 mLs, and her IJ site is clean, dry and intact.

Question 1. Using the MEWS scoring chart on the following page, what is this patient's MEWS score?

The patient's midnight labs come back:

Platelets: 140 BUN: 24

Hemoglobin: 13 Creatinine: 1.8

White Count: 12,000 Glucose: 120

Bilirubin: 4.1

Question 2. Using the qSofa chart on the following page, what is the patient's score?

Question 3. The patient's assessment score triggers the facility's sepsis protocol. For patients with suspected sepsis, what are 4 priority actions to be completed in the first hour according to the ACCN's sepsis recommendations?

Question 4. Sepsis is always preceded by infection. What are the potential sites of infection for the above client?

Reference no: EM133398205

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