Medical inpatient unit, 0740 handover
Sepsis on a medical unit
A 74-year-old admitted for a urinary tract infection becomes confused and tachycardic on day two. Six items from first cue to reassessment.
0710. Client is a 74-year-old admitted 2 days ago with a urinary tract infection. Overnight nurse reports the client was pulling at the intravenous line and asking to go home, which is new. Client is normally oriented to person, place and time and lives independently with a spouse. This morning the client is oriented to person only and does not recall the admission. Skin is warm and flushed. Radial pulse is rapid and thready. Client reports feeling cold and is asking for a second blanket. Voided 90 mL of dark, strong-smelling urine since 2300.
Select the findings in the nurses' note that require immediate follow-up.
Highlight only findings that would change your nursing action. Highlighting a normal finding subtracts a point.
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