Urosepsis Jean Kelly age 82 Name: Christina Hammack
One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed
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Urosepsis Jean Kelly age 82 Name: Christina Hammack
One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that then initiated a “domino effect” in their life? ● Circle what PMH problem started FIRST • DMII ● Underline what PMH problem(s) FOLLOWED as dominoes • HTN, HLD (probably coexisted), Gout • Wasn’t exactly sure when Gout could have happened as it not necessarily linked to her other comorbidities
Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 101.8 F/38.8 C (oral) Provoking/Palliative: Nothing/Nothing P: 110 (regular) Quality: Ache R: 24 (regular) Region/Radiation: Right flank BP: 102/50 Severity: 5/10 O2 sat: 98% room air Timing: Continuous
The nurse recognizes the need to validate his/her concern of fluid volume deficit and performs a set of orthostatic VS and obtains the following:
Position: HR: BP: Supine 110 102/50 Standing 132 92/42
What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: Temp of 101.8F Indicative of fever, systemic sign of infection
Pulse of 110 Tachycardia, heart is beating faster - could be sign of anxiety or compensation of some sort
Respirations of 24 Tachypnea could also be a sign of anxiety or compensation
BP 102/50 In combination with tachycardia, probably indicative of fluid volume deficit in which heart beats faster to maintain pressure with the decreased blood volume
Orthostatic BP changes Orthostatic hypotension defined as a systolic change of at least 20 between supine and standing which she demonstrates. Indicative of many things but given her vitals and s/s, this is consistent with fluid volume
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