Emergency Department Nurses' Notes

0632: 77-year-old male arrived via ambulance from a long-term care facility with manifestations of infection. The client was found extremely lethargic and hot to touch. The client had a temperature of 102°F (39°). The client has a medical history of hyperlipidemia, advanced Alzheimer's disease, hypertension, diabetes mellitus (type two), and osteoarthritis.

0710: Assessment completed: Vital signs: T 103°F (39.4°C), P 109, RR 25, BP 113/85 (MAP 94 mm Hg), pulse oximetry reading 95% on oxygen at 2 L/min via nasal cannula. The client's breathing appears slightly labored; tachypnea, rhonchi, and wheezing are noted in the bilateral lung bases. Skin hot to the touch and extremely dry and flaky. Peripheral pulses 2+ and regular. Sinus tachycardia on cardiac monitor. Capillary refill is 3 seconds. Client is lethargic and fully disoriented. 20-gauge Peripheral vascular access device (VAD) placed in the right forearm. Point of care (POC) lactic acid obtained: 4.3 mmol/L [< 2 mmo/L].

0720: Critical results received and read back from lab: potassium 5.5 mEq/L [3.5-5.0 mEq/L); creatinine 3.2 mg/dL [0.6-1.2 mg/dL]; BUN 40 mg/dL [10-20 mg/dL). ABG results received: pH: 7.29 [7.35-7.45] CO2: 45 [35-45] HCO-3 17 [22-28]. POC capillary blood glucose: 149 mg/dL (70-110 mg/dL). Physician notified of results.

0815: Prescribed fluid bolus finished. Post fluid bolus VS: T 102°F (39°C), P 118, RR 24, BP 101/82 (MAP 88 mm Hg), pulse oximetry reading 95% on oxygen at 2 L/min via nasal cannula. Telephone report was given to intensive care nurse at this time. IV antibiotics infusing at this time.

0825: Second peripheral vascular access device established in the left antecubital space. 18-gauge successfully started x 1 attempt.

0900: Client transported via stretcher to ICU with nurse transport

Intensive Care Unit Nurses' Notes

0915: Client transported to the ICU. VS: Vital signs: T 100° F (37.8° C), P 126, RR 22, BP 84/51 (MAP 62 mm Hg), pulse oximetry reading 96% on oxygen at 2 L/min via nasal cannula. Physician called at this time with RE: vital signs. POC lactic acid obtained: 4.1 mmol/L [< 2 mmo/L]. Assessment completed: Tachypnea and diminished lung sounds are noted in the bilateral lung bases. Skin warm to the touch and mottled. Bruising and petechiae were noted on the torso of the client. Peripheral pulses 1+ and regular. Sinus tachycardia on the cardiac monitor with peaked T-waves. Capillary refill is > 3 seconds. Client is lethargic and fully disoriented.

Emergency Department Orders

0715:

• Obtain laboratory work - CBC, CMP, lactic acid, blood cultures x 2, urine analysis, sputum sample
• 30 mL/kg of 0.9% sodium chloride (normal saline) bolus over one hour
• Chest x-ray
• Start two peripheral vascular access devices
• Albuterol nebulizer treatment x 1 dose - now
• Admit to intensive care unit for pneumonia and septic shock
• Continuous cardiac monitoring
• Arterial blood gas
• Intravenous azithromycin - pharmacy to dose
• ketorolac 15 mg intravnous push (IVP) x 1 dose for fever
• Intravenous ceftriaxone - pharmacy to dose
• Consult intensivist and infectious disease

ICU Orders

0940:

• dopamine 5 mcg/kg/min - titrate to maintain a MAP > 70
• insert an indwelling urinary catheter
• obtain aPTT, PT/INR, platelet count
• one ampule of sodium bicarbonate intravenous push
• repeat ABG 15 minutes after sodium bicarbonate infusion
• 5 units of regular insulin intravenous push (IVP)
• prepare the client for an intrajugular central line insertion

Chest radiograph

0815 - Chest radiograph shows reticulonodular opacities and significant focal consolidation in the left and right middle to lower lung field

Emergency Department Nurses' Notes

0632: 77-year-old male arrived via ambulance from a long-term care facility with manifestations of infection. The client was found extremely lethargic and hot to touch. The client had a temperature of 102°F (39°). The client has a medical history of hyperlipidemia, advanced Alzheimer's disease, hypertension, diabetes mellitus (type two), and osteoarthritis.

0710: Assessment completed: Vital signs: T 103°F (39.4°C), P 109, RR 25, BP 113/85 (MAP 94 mm Hg), pulse oximetry reading 95% on oxygen at 2 L/min via nasal cannula. The client's breathing appears slightly labored; tachypnea, rhonchi, and wheezing are noted in the bilateral lung bases. Skin hot to the touch and extremely dry and flaky. Peripheral pulses 2+ and regular. Sinus tachycardia on cardiac monitor. Capillary refill is 3 seconds. Client is lethargic and fully disoriented. 20-gauge Peripheral vascular access device (VAD) placed in the right forearm. Point of care (POC) lactic acid obtained: 4.3 mmol/L [< 2 mmo/L].

0720: Critical results received and read back from lab: potassium 5.5 mEq/L [3.5-5.0 mEq/L); creatinine 3.2 mg/dL [0.6-1.2 mg/dL]; BUN 40 mg/dL [10-20 mg/dL). ABG results received: pH: 7.29 [7.35-7.45] CO2: 45 [35-45] HCO-3 17 [22-28]. POC capillary blood glucose: 149 mg/dL (70-110 mg/dL). Physician notified of results.

0815: Prescribed fluid bolus finished. Post fluid bolus VS: T 102°F (39°C), P 118, RR 24, BP 101/82 (MAP 88 mm Hg), pulse oximetry reading 95% on oxygen at 2 L/min via nasal cannula. Telephone report was given to intensive care nurse at this time. IV antibiotics infusing at this time.

0825: Second peripheral vascular access device established in the left antecubital space. 18-gauge successfully started x 1 attempt.

0900: Client transported via stretcher to ICU with nurse transport

Intensive Care Unit Nurses' Notes

0915: Client transported to the ICU. VS: Vital signs: T 100° F (37.8° C), P 126, RR 22, BP 88/59 (MAP 69 mm Hg), pulse oximetry reading 96% on oxygen at 2 L/min via nasal cannula. Physician called at this time with RE: vital signs. POC lactic acid obtained: 4.1 mmol/L [< 2 mmo/L]. Assessment completed: Tachypnea and diminished lung sounds are noted in the bilateral lung bases. Skin warm to the touch and mottled. Bruising and petechiae were noted on the torso of the client. Peripheral pulses 1+ and regular. Sinus tachycardia on the cardiac monitor with peaked T-waves. Capillary refill is > 3 seconds. Client is lethargic and fully disoriented.