Sepsis NGN Case Study

Most concerning cues: new confusion (oriented ×2 from ×4 — altered mentation in an older adult is often the first sepsis sign), fever 38.4°C, HR 112, RR 24, BP 102/58 against a hypertensive baseline, urine output 25 mL/hr and cloudy with a day-3 catheter, glucose 218 in a known diabetic (stress response), warm flushed skin.

Relevant but less urgent: incision redness with scant drainage (a possible source, not yet alarming alone).

The trap: accepting “probably just hospital delirium” at face value. New confusion plus abnormal vitals is sepsis until proven otherwise — especially in older adults, who may never spike a high fever.

Sepsis (most supported): infection source candidates (catheter day 3 — CAUTI; surgical site; pneumonia risk post-op) + systemic response (fever, tachycardia, tachypnea, relative hypotension, altered mentation, falling urine output). She meets SIRS-style criteria and has organ-dysfunction signals (mentation, urine output, BP trend).

Hypovolemia alone: could explain tachycardia, low urine output, and soft BP — but not fever, cloudy urine, or confusion as cleanly.

Hyperglycemic crisis: glucose 218 is stress-level, nowhere near HHS territory; doesn’t explain fever.

Simple delirium: explains confusion only — and delirium in a post-op elder demands a cause anyway. Infection is the most common one.

1. Sepsis, likely urinary or surgical source — highest probability and highest consequence. Sepsis mortality climbs with every hour of delayed treatment, which makes it the priority even before it’s confirmed.

2. Hypovolemia — likely coexisting and addressed by the same initial actions (fluids, monitoring).

3. Delirium of other cause — kept on the list, worked up after the life threat is addressed.

NGN logic: prioritize by probability × urgency. A likely, lethal, time-sensitive condition outranks everything merely possible or merely uncomfortable.

Immediate nursing actions: notify the provider/rapid response per protocol using SBAR; full vitals with a manual BP; place on continuous monitoring; raise HOB, apply oxygen if saturation drops further per protocol; ensure patent IV access (anticipate a second line).

Anticipated orders (the sepsis bundle): blood cultures ×2 before antibiotics, lactate level, urinalysis and urine culture, CBC/CMP, broad-spectrum antibiotics within the first hour, and a 30 mL/kg crystalloid bolus for hypotension/lactate elevation per orders.

Also reasonable: strict I&O, glucose monitoring, evaluating whether the catheter can come out or be replaced (source control).

Draw the cultures first, then hang the antibiotic — cultures drawn after antibiotics may be falsely negative, costing the team the organism and targeted therapy. The exception: never let culture logistics delay antibiotics beyond the bundle window — escalate immediately if cultures can’t be obtained promptly.

While infusing: start the fluid bolus per orders (watching an older heart — listen for crackles, monitor for respiratory worsening), recheck vitals per protocol, and keep the family informed about the change in plan.

Improving: BP and heart rate trending toward baseline, mentation clearing (×2 → ×3), urine output rising, respiratory rate settling — perfusion is recovering.

Still watching: the repeat lactate (clearance is the marker that matters), temperature curve, culture results for antibiotic targeting, fluid tolerance in a 72-year-old (crackles, oxygen needs), and glucose.

Not resolved: source control — the catheter and the incision still need a plan. Evaluation isn’t a checkbox; it loops you back to Step 1 with fresh cues.