Sepsis in an older adult with pneumonia
One client, 6 questions, one record that stays open beside every one of them. Notice what matters, work out what it means, decide what is most likely, plan, act, then judge whether it worked.
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Click to highlight the findings in this nurses' note that require immediate follow-up.
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Client is more confused than this morning and does not recognize his daughter. Skin is warm and flushed. Respirations are shallow and rapid. Reports feeling cold despite a temperature of 38.9 C. Urine output has been 20 mL/hr for the past three hours. Bilateral crackles unchanged from admission. Peripheral intravenous line in the left forearm is patent without redness.