545 CASE SCENARIO. SEVERE SEPSIS/ HYPOTENSION.

Sepsis is the complications of life threatening infection.The most common causes of Sepsis is bacteria infection.It can lead to multiple organ failures. So treatment should be started upon arrival to emergency room immediately and Sepsis alert started and announced.

Symptoms are : fever,fast heart rate, some mental confusion, low blood pressure, and difficulty with breathing.

Treatment is usually Antibiotics and hydration.

Monitor temperature,and lactic acid level.

KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

On Sepsis Alert.

Came into Emergency room with fever of 102.7°F

Age/Sex :65years old man.

Account number : Q005634372.

MR # : Q00058867522.

Admission date: June 10th 2021@04am.

Status: Inpatient admit.

Location : MedTelemetry.

Room :42114.

Attending doctor : Tommy Holbib.

Patient name : Money,Talks.

Resuscitation Status : Full code.

Primary diagnosis : Severe Sepsis/Hypotension. Secondary diagnosis: SOB,Prostate Cancer.S/P Radiation.

Chemotherapy 4days ago.

On Chemo treatment

Weight: 185lbs.

Height : 5feet 8inches.

Alert and oriented x4.

Allergy: NKDA.

Isolation Status :Standard Precautions.

Risk for fall:No.

Bathroom privileges.

Skin intergrity impaired: No.

Do patient have advance Directive:No.

Copy of advance Directive on the chart.

Diet: NPO after midnight for Bronchoscopy at 4pm.

Informed consent signed and dated in patient chart.

Ambulates to the bathroom.

02 @ 2liter NC.

No edema noted.

Doctor orders:

Blood culture done,result pending result.

Abcess to old porter cath site biopsy done.

CXR revealed Bronchitis.

Vancomycin 1gm IV Q12hours.

Rocephin 1gm IV Q24hours .

0.9NS @ 50ml/hour IV right forearm 18guage clean / Patent/ Intact.

Normal Saline 500ml× 2.

Acyclovir 250mg po Q12hours.

Morphine sulfate 4mg IV Q4hours prn severe pain.

Zofran 4mg IV Q4hours prn nausea/vomiting.

Dilaudid 0.5mg IV Q3hours prn severe pain. Norco 10/325mg 1tablet po Q4hours prn moderate pain.

Infectious disease doctor: Green Wealth on board.

Continue with Antibiotics check lab values ESR,LDH,CRP.

Case manager consult for placement.

Laboratory results :

WBC 13.5.

H/ H 8.5/ 24.0.

K: 3.6.Replaced 20meqkcl .

Na: 135.

Ca+ 8.6.

Magnesium level 1.7 replacement order pending. Laboratory tests CBC with differential, Comprehensive Metabolic panel, magnesium, ESR,LDH, CRP in am.

Discharge home with wife when medically stable.

08amVital signs : Bp 132/76,Heart rate 89, Temperature 98.9°F,Respiration: 18,02 Saturation 94%.

At 12noon : Bp 122/78,Hr: 86,Temperature 98.4°f,Respiration 18,02 on room air 93°f.

At 1600: Bp 117/76,Hr. 78, Temperature 97.4.Respiration 19,02 sat 94RA,

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

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