Intensive Care Nursing/Sepsis Scenarios/Medical Sepsis Unfolding Case Study/Medical Sepsis Scenario p2

Arrival to unit
Upon arrival to your unit, the patient begins to decompensate further. You initially apply oxygen as their oxygen saturation is 88% on RA and notify provider to assist with rapid order entry. The family has just arrived and states the patient had not urinated in the prior 20 hours and bladder scanning shows 50 mL fluid volume. A urinary catheter is placed for accurate urine output measurement in an acutely ill patient. Broad spectrum antibiotics (Vancomycin and Piperacillin/Tazobactam) and fluid bolus were initiated in the ED. On account of the low urine volume, the provider has ordered a renal ultrasound.

Current vital signs and recently resulted labs are as follows:

Temperature: 39.5 C (103.1 F)

HR: 145

BP: 78/40

RR: 27

SpO2: 96% @ 2LNC

Sodium: 130

Creatine: 2.2

{Which of the vital signs or labs are concerning to you at this time? +Creatine -Oxygen Saturation +Blood Pressure +Heart Rate
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 * 1) /Medical Sepsis Scenario p3/