0830: Client is an 84-year-old female with a history of diabetes mellitus (type two), hypertension, osteoarthritis, COPD, and chronic pain who presented to the ED with confusion, nausea, vomiting, and decreased oral intake. Her daughter provided the history, as the client was disoriented to time and place with a GCS of 13. She reports a one-week history of burning with urination, increased frequency, and cloudy, foul-smelling urine. There are no reports of recent falls, trauma, or new medications. On assessment, the client appeared pale, cool, and clammy with capillary refill greater than 3 seconds. She was tachypneic and using accessory muscles to breathe, and her abdomen was distended with decreased bowel sounds. Urine output was dark and concentrated.

STAT:

• Complete Blood Count (CBC) with Differential
• Basic Metabolic Panel (BMP)
• Urinalysis (UA) and Urine Culture
• Serum Lactate
• Portable Chest X-Ray
• Abdominal/Pelvis CT with Contrast

0900

Abdominal and Pelvic CT Scan with Contrast

The CT scan revealed enlarged kidneys with signs of inflammation, including surrounding tissue swelling. There were no obstructions or fluid collections observed. These findings are consistent with pyelonephritis.

Chest X-ray

The chest X-ray showed clear lungs without signs of infection, such as pneumonia. The heart size and shape were normal, and there were no issues with the pleura. This suggests that the source of infection is not pulmonary.

0930

• Insert 2 large-bore IVs
• Administer acetaminophen PO
• Begin piperacillin-tazobactam IV
• Initiate 0.9% NS bolus at 30 mL/kg
• Obtain blood cultures x2
• Place sequential compression devices
• Administer Regular Insulin (Novalin R) per sliding scale AC/HS

1000: Client is alert and completely oriented, IV access was established in the left forearm using a 20-gauge catheter. A 1-liter bolus of 0.9% normal saline was initiated at 250 mL/hr per sepsis protocol. Blood cultures were drawn from two sites before initiating antibiotics. Broad-spectrum antibiotics (piperacillin-tazobactam 3.375 g IV) were administered as ordered. Acetaminophen 650 mg PO was given to manage fever. Oxygen was applied at 2 L/min via nasal cannula to maintain SpO₂ above 94%. Client remained hypotensive with MAP < 65 mmHg; closely monitoring vitals and urine output. Compression stockings were applied bilaterally for DVT prophylaxis. The client was placed on fall precautions and continuous pulse oximetry. Handoff report given to the ICU nurse for transfer of care.