Terms in this set (16)
The patient is in the ICU with pneumonia. The HR 90, O2 stat 89%, Decreased BP, and Creatinine 2.9. What is the nurses priority?
Give IV antibiotics (to prevent septic Shock)
Sepsis patient what is the order of interventions?
1st IV fluids
Which statement made by the family member of a patient with severe sepsis would be of concern to the RN?
I will wait here until he gets better
ICU client has oliguria, increase creatinine, tachypnea, and altered LOC; the patient is presenting what stage of sepsis.
The nurse is caring for a patient with sepsis. At the beginning of the shift, the patient is in a hypodynamic state. Several hours later, the patient's BP is elevated and pulse is bounding. How does the nurse interpret this change?
1. A positive response & a signal of recovery
2. Temporary situation that is likely to normalize
3. Worsening of the condition rather than improvement
4. Expected response to standard therapies
Which clinical manifestations will a patient show In the first stage if sepsis?
1. Temp 102.0
2. RR 30
3. HR 104
(Not the BP answer)
A patient that is 5 days post op, has bowel perforation, oliguria, increased WBC's, and edema, what are these symptoms a sign of?
Which of the following lab values suggest that the patient has DIC?
Increased D Dimer
Not decreased PTT (supposed to be increased PT and PTT)
Not decreased PT
A patient with sepsis with compromised endothelium cells
1. Fluid coming out of the vascular space
2. No clotting factors left in the large vessels or arteries (this happened b/c of fibrinolysis - broke down the clots)
A patient with severe sepsis gets a 500cc bolus of NS which increases their BP, What are appropriate interventions at this stage?
1. Fluid resuscitation
2. Culture specific antibiotic therapy
The patient has DIC what are the signs that are expected to manifest in this patient?
Bleeding from the catheter
Which of the following patients has the greatest risk for sepsis?
An 84 year old patient with a foley
Which of these patients is at greatest risk for DIC?
Patient with Septicemia
Which of these is a goal for a patient with Sepsis
1. Glucose less than 180 (gave 155)
Not the CVP of 20 normal CVP 2-8
Not lactic acid of 4 because norm is less than 2
Patient blood pressure is 76/66, after fluid resuscitation the patient's blood pressure is 89/75. What stage are they in?
What are the signs and symptoms of SIRS
Temp > 38 C (100.4 F)
Temp < 36 C (96.8 F)
HR > 90 bpm
RR > 20/min
PaCO2 < 32 mmHg (Alkalosis)
WBC > 12,000
WBC < 4,000
> 10% bands
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