[Case Study 1, Screen 1.] The provider diagnoses sepsis with a suspected urinary source. Which interventions should the nurse anticipate in the initial management of this client? Select all that apply.

CLIENT
63-year-old woman. Weight 70 kg.
History: type 2 diabetes (takes metformin), hypertension (takes lisinopril).
Lives with spouse; independent in all activities; baseline fully oriented.
Home blood pressure readings usually about 132/78 mm Hg.

NURSES' NOTES - 0800
Spouse reports the client has been "sleepy and confused" since last night.
Client reports burning on urination for 3 days and has been eating and
drinking very little for 2 days. Oriented to person only. Skin warm and
flushed; mucous membranes dry. Reports right flank pain, 5/10. Lungs clear
bilaterally. Capillary refill 3 seconds. Last voided a small amount of dark
urine early this morning.

VITAL SIGNS - 0800
Temperature      39.0°C (102.2°F)
Heart rate       116/min
Respiratory rate 24/min
Blood pressure   88/50 mm Hg (MAP 63 mm Hg)
SpO2             95% on room air

LABORATORY RESULTS - 0815            Result            Reference range
WBC                                  18,600/mm³        5,000-10,000/mm³
  Bands                              14%               0-5%
Lactate                              4.1 mmol/L        0.5-2.0 mmol/L
Creatinine                           1.9 mg/dL         0.5-1.1 mg/dL
  (baseline 1 month ago: 0.9 mg/dL)
BUN                                  40 mg/dL          7-20 mg/dL
Glucose (random)                     238 mg/dL         70-140 mg/dL
Sodium                               137 mEq/L         135-145 mEq/L
Potassium                            4.6 mEq/L         3.5-5.0 mEq/L
Platelets                            172,000/mm³       150,000-400,000/mm³
Urinalysis: cloudy; nitrite positive; leukocyte esterase positive;
            WBC more than 50/hpf

AObtain two sets of blood cultures before the first antimicrobial dose, without delaying the antimicrobial.
BGive the client's scheduled metformin dose with breakfast.
CBegin IV lactated Ringer's solution 2,100 mL (30 mL/kg), to be completed within 3 hours.
DAdminister a broad-spectrum IV antimicrobial within 1 hour.
EHold antimicrobials until the urine culture identifies the organism.
FRemeasure the serum lactate after initial fluid resuscitation.

Show answer and explanations

Answer

A, C, D, F

A: Cultures before antibiotics support identification when they do not delay urgent treatment. B: Acute shock and renal dysfunction require review of metformin rather than routine administration. C: The stated initial crystalloid plan addresses sepsis-related hypoperfusion, with ongoing reassessment. D: Prompt broad-spectrum antimicrobial treatment is appropriate for this high-likelihood severe infection. E: Waiting for final culture identification would delay urgent therapy. F: Repeat lactate helps assess the response and ongoing perfusion concern.

A

Cultures before antibiotics support identification when they do not delay urgent treatment.

B

Acute shock and renal dysfunction require review of metformin rather than routine administration.

C

The stated initial crystalloid plan addresses sepsis-related hypoperfusion, with ongoing reassessment.

D

Prompt broad-spectrum antimicrobial treatment is appropriate for this high-likelihood severe infection.

E

Waiting for final culture identification would delay urgent therapy.

F

Repeat lactate helps assess the response and ongoing perfusion concern.