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Sepsis Case Study

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Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Personal/Social History: Jean lives independently in a senior apartment retirement community. She is widowed and has two daughters who are active and involved in her life. What data from the histories are important and RELEVANT and have clinical significance for the nurse? RELEVANT Data from Present Problem: Clinical Significance: Progressively worsening fatigue, fever, and painful, burning, and frequent urination. Sudden onset of confusion (change in mental status) with no prior history Clinically significant symptoms of urinary tract infection prompting request for an order for a urinalysis. Confusion is a common presentation of UTI in the elderly, and change in mental status from baseline should always be fully investigated. RELEVANT Data from Social History: Clinical Significance: Lives in a senior retirement community with daughters who are actively involved in her life and wears a life alert button Jean has a strong support system and a safe place to return to after discharge that will provide support. Her life alert button provides the security she needs in the event of an emergency since she lives alone. What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medications treat which conditions-indicate with numbers or some form that I can identify PMH: Home Meds: Pharm. Classification: Expected Outcome: Diabetes type 2 1. Allopurinol 100 mg PO 1. Antigout agent 1. Decreased production of uric acid to reduce gout flares 2. Reduce platelet aggregation and clumping to prevent clotting 3. Reduces and controls blood glucose levels 4. Reduces cholesterol/ blood lipid levels 5. Reduces blood pressure 6. Reduces blood pressure 7. Reduces BP through diuresis 8. Replaces K in the body lost through diuresis Hyperlipidemia bid 2. ASA 81 mg PO daily 3. Pioglitazone 15 mg PO daily 4. Simvastatin 20 mg PO daily 5. Metoprolol 25 mg PO bid 6. Lisinopril 10 mg PO daily 7. Furosemide 20 mg PO daily 8. Potassium chloride 20 mEq PO daily 2. Antiplatelet/salicylate 3. Thiazolidinedione/anti diabetic 4. Antihyperlipidemic 5. Beta blocker Hypertension (HTN) Gout 6. Ace inhibitor 7. Loop diuretic 8. K supplement ................................................................CONTINUED........................................

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