Intensive Care Nursing/Sepsis Scenarios/Medical Sepsis Unfolding Case Study 2/Medical Sepsis Scenario 2 p2

Arrival to unit
Broad spectrum antibiotics (Vancomycin and Piperacillin/Tazobactam) and fluid bolus were initiated in the ED. Upon arrival to your unit, the patient begins to become more agitated and vomits again after screaming about the overbed fluorescent lighting. You initially attempt to redirect the patient and try to contact family to assist with calming your patient. These attempts to redirect are met with more hostility and the patient ended up having a seizure as the provider was arriving. The provider has ordered a CT of the head, EEG, and asked you to assist with a lumbar puncture. You were able to complete the emergent lumbar puncture with the provider prior to the end of your shift.

Current vital signs and recently resulted labs are as follows:

Temperature: 39 C (102.2 F)

HR: 112

BP: 96/63

RR: 20

SpO2: 96%

{Which of the vital signs or findings are concerning to you at this time? +Photophobia +Seizure -Blood Pressure +Temperature
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 * 1) /Medical Sepsis Scenario 2 p3/