Sepsis

NURSING SCHOOL JEWELS

Admission snapshot

Chief complaint

“I feel shaky and can't get warm.” Her daughter reports two days of burning urination and one day of fever and increasing weakness.

HPI

Reduced oral intake since yesterday. Right flank discomfort began overnight. At home this morning Jordan needed help standing and seemed unusually slow to answer questions.

Medical history

Type 2 diabetes, hypertension, prior kidney stone. Baseline creatinine approximately 0.9 mg/dL in records from three months ago.

Home medications

Metformin 500 mg PO twice daily; lisinopril 10 mg PO daily. Medication reconciliation pending.

Social history

Lives with daughter; independent in daily activities at baseline. No tobacco use; occasional alcohol.

Learning focus

Recognize deterioration, respond to septic shock, and identify when an infected urinary obstruction needs source control.

Patient timeline

08:10

Notes

Provider note

08:18 · Dr. Camille Price · Emergency Medicine

HPI: Dysuria and urinary frequency for two days, fever and rigors since yesterday, new right flank pain overnight. Daughter describes decreased activity and slower responses this morning. No cough, dyspnea, diarrhea, or recent antibiotic use.

Exam: Ill appearing, febrile, dry oral mucosa, tachycardic, right costovertebral angle tenderness, no abdominal guarding. Awake and oriented, but responses are slower than baseline. Lungs clear.

Assessment: Probable urinary source sepsis with early hypoperfusion and acute kidney injury. Pyelonephritis likely; obstruction is possible given stone history and flank pain. Evaluate rapidly for an infected obstructing stone.

Plan: Sepsis response initiated. Blood cultures and urine specimen before antibiotics if readily obtained, prompt IV antimicrobial therapy, lactate, IV crystalloid with repeated perfusion and lung assessment, and urgent noncontrast CT of abdomen/pelvis to evaluate obstruction. Monitor urine output and escalate any falling pressure or worsening mentation.

Signed: Camille Price, MD · 08:20

Nursing note

08:10–08:42 · T. Morgan, RN · ED

Patient states, “It burns when I go, and my back aches.” Daughter confirms independent baseline but notes unusual weakness and delayed answers today. T 39.1°C, HR 118, BP 96/58, RR 24. Skin warm and flushed; capillary refill approximately 3 seconds. Two peripheral IVs placed. Dr. Price notified of sepsis screen at 08:13. Blood cultures obtained at 08:22 and 08:26; urine sent at 08:29. First balanced crystalloid liter started at 08:32; ceftriaxone started at 08:39. Reassessment and repeat lactate scheduled.

Vital signs

Measure	08:10	Reference / goal
Temperature	39.1°C / 102.4°F	~36.1–37.2°C
Heart rate	118/min	60–100/min
Respirations	24/min	12–20/min
Blood pressure	96/58 mmHg (MAP ~71)	Trend perfusion; shock target individualized
SpO₂	96% room air	Clinical context
Mental status	Oriented, slower responses	Compare with baseline
Urine output	Not yet quantified	Strict intake / output

Focused assessment

Neuro: Oriented × 4; delayed responses compared with baseline.
Cardiovascular: Tachycardic, no chest pain; capillary refill ~3 seconds.
Respiratory: Tachypneic; lungs clear, no accessory muscle use.
GU / renal: Dysuria, frequency, right flank tenderness; no gross hematuria reported.
Skin / fluid: Warm, flushed, dry mucous membranes; poor oral intake.

Labs

Test	08:10	Reference*
WBC	17.2 ×10³/µL H	4.0–11.0 ×10³/µL
Lactate	2.4 mmol/L H	0.5–2.0 mmol/L
Creatinine	1.4 mg/dL H	0.6–1.2 mg/dL; baseline ~0.9
BUN	27 mg/dL H	7–20 mg/dL
Sodium	134 mmol/L L	135–145 mmol/L
Potassium	4.2 mmol/L	3.5–5.0 mmol/L
Glucose	186 mg/dL H	70–99 mg/dL fasting†
Urinalysis	Leukocyte esterase +; nitrites +; >50 WBC/hpf	Negative; 0–5 WBC/hpf
Blood / urine cultures	Collected; pending	Final growth and susceptibility pending

*Illustrative adult ranges; use the reporting laboratory’s intervals. †This patient is acutely ill and not fasting; interpret glucose in context. Pending cultures are not negative cultures.

Diagnostics

ECG: sinus tachycardia. Urgent noncontrast CT abdomen/pelvis requested because flank pain and stone history raise concern for urinary obstruction; no result yet.

Provider orders

Activate sepsis response; obtain two sets of blood cultures, urine culture, CBC, metabolic panel, and lactate.
Balanced crystalloid 1,000 mL IV now; reassess blood pressure, mentation, lung sounds, capillary refill, and urine output.
Ceftriaxone 2 g IV once after cultures, without delaying needed antimicrobial therapy.
Repeat lactate in approximately 2 hours; vital signs every 15 minutes until stable; strict intake/output.
Urgent noncontrast CT abdomen/pelvis; notify provider immediately if hypotension, confusion, or oliguria develops.
Hold lisinopril during hypotension and metformin during acute kidney injury pending reassessment.

MAR · Medication administration

Medication / fluid	Order	Given / status	Nursing consideration
Balanced crystalloid	1,000 mL IV bolus	Started 08:32; infusing	Reassess perfusion and lungs.
Ceftriaxone	2 g IV once	Started 08:39	Two blood cultures collected first.
Metformin / lisinopril	Home medications	Held; not administered	AKI and hypotension; provider aware.

Pause & decide · Before the next timestamp

Question 1 · Recognize cues List four findings that need immediate follow-up. Which cue shows possible organ dysfunction?

Question 2 · Generate solutions What actions should the nurse make sure happen now while the CT result is pending? Put them in priority order.

10:30

Notes

Provider reassessment

10:37 · Dr. Camille Price · Emergency Medicine

Interval: Despite completion of the first liter of crystalloid and initial antimicrobial therapy, pressure is now 82/48 (MAP ~59), lactate has risen to 4.1, urine output was 20 mL over the preceding two hours, and patient is newly disoriented to date. Right flank pain persists.

Assessment: Septic shock with worsening renal hypoperfusion and probable urinary source. Obstructing infected stone must be ruled out immediately.

Plan: Continue crystalloid resuscitation to approximately 2.1 L total for 70 kg (30 mL/kg) with frequent reassessment; begin norepinephrine for persistent hypotension while fluid is administered, titrating per protocol to MAP near 65. Transfer to ICU, urgently complete CT and consult urology if obstruction is found. Escalate empiric antibiotic to piperacillin–tazobactam per local protocol and review culture data for narrowing later. Check IV patency, urine output, respiratory status, and serial lactate.

Signed: Camille Price, MD · 10:41

Nursing note

10:30–11:05 · T. Morgan, RN · ED

Patient says, “I feel dizzy.” She incorrectly states the month, which daughter says is new. BP 82/48 confirmed manually, HR 132, RR 28, capillary refill ~5 seconds, extremities cool and mottled at knees. Measured urine output 20 mL during 08:30–10:30. Dr. Price notified immediately at 10:32; bedside sepsis huddle completed. Second IV checked for brisk blood return. Additional crystalloid started at 10:43 and norepinephrine at 10:48 per protocol with frequent BP and IV site checks. ICU and CT teams contacted; urology alerted after CT result.

Vital signs

Measure	08:10	10:30	Reference / goal
Temperature	39.1°C	39.3°C / 102.7°F	~36.1–37.2°C
Heart rate	118	132/min	60–100/min
Respirations	24	28/min	12–20/min
Blood pressure	96/58 (MAP ~71)	82/48 (MAP ~59)	Initial shock MAP target ~65*
SpO₂	96% RA	94% RA	Assess trend and work of breathing
Mental status	Slower responses	Disoriented to date	At baseline oriented × 4
Urine output	Not quantified	20 mL / 2 hr	Trend with perfusion / renal status

*The treating team individualizes the BP target; ~65 mmHg is an initial adult septic shock target in the guideline.

Focused assessment

Neuro: Newly disoriented to date; follows commands but less attentive.
Cardiovascular: Tachycardic; manual BP confirms hypotension, weak peripheral pulses, capillary refill ~5 seconds.
Respiratory: RR 28, lungs still clear; monitor for fluid intolerance.
GU / renal: 20 mL urine output in 2 hr, persistent right flank tenderness.
Skin: Cool extremities, mottling near knees.

Labs

Test	08:10	10:30	Reference*
WBC	17.2 H	20.1 H	4.0–11.0 ×10³/µL
Lactate	2.4 H	4.1 mmol/L H	0.5–2.0 mmol/L
Creatinine	1.4 H	1.7 mg/dL H	0.6–1.2 mg/dL
BUN	27 H	32 mg/dL H	7–20 mg/dL
Sodium	134 L	133 mmol/L L	135–145 mmol/L
Potassium	4.2	4.3 mmol/L	3.5–5.0 mmol/L
Glucose	186 H	202 mg/dL H	70–99 mg/dL fasting†
Urinalysis	LE +, nitrites +, >50 WBC/hpf	Not repeated	Negative; 0–5 WBC/hpf
Cultures	Collected	Pending; no final result	Follow final identification / susceptibility

*Illustrative ranges. †Fasting glucose interval is shown for orientation only.

Diagnostics

10:50 CT abdomen/pelvis, noncontrast: 6 mm obstructing right proximal ureteral calculus with moderate hydronephrosis and perinephric stranding. In the setting of sepsis, this is a potentially infected obstructed collecting system. Urology recommends urgent decompression; antibiotics alone cannot reliably drain the obstruction.

Provider orders

Complete additional 1,100 mL balanced crystalloid to reach approximately 2,100 mL total initial volume for 70 kg; reassess lungs, perfusion, and BP throughout.
Norepinephrine infusion per ICU protocol for persistent hypotension; titrate to ordered MAP goal and monitor peripheral IV site closely.
Stop further ceftriaxone; begin piperacillin–tazobactam 4.5 g IV now, with subsequent dose and renal adjustment per pharmacy and local policy.
Urgent CT result notification and urology consult for decompression; keep NPO for possible procedure.
Transfer to ICU; monitor BP frequently, strict intake/output, repeat lactate and metabolic panel after resuscitation.

MAR · Medication administration

Medication / fluid	Order	Given / status	Nursing consideration
Balanced crystalloid	1,000 mL + 1,100 mL IV	First liter completed 09:25; additional fluid begun 10:43	Target total ~2.1 L; reassess for overload.
Ceftriaxone	2 g IV once	Completed 09:09	Initial empiric therapy; no repeat dose scheduled.
Norepinephrine	IV infusion, titrate to MAP order	Started 10:48 via monitored peripheral IV	Frequent BP and IV site checks; ICU handoff.
Piperacillin–tazobactam	4.5 g IV loading dose	Started 10:58	Review renal dosing and culture results.

Pause & decide · Before the next timestamp

Question 1 · Analyze cues / take action Why is this now septic shock? Name the three most urgent nursing actions, and explain what the CT changes about the plan.

Question 2 · Prioritize / anticipate The CT shows an obstructed, potentially infected collecting system. What must the nurse coordinate before transfer or the procedure, and what deterioration must still be watched for?

14:45

Notes

Provider / urology note

14:52 · Dr. Camille Price and Dr. Nadia Shah · ICU / Urology

Interval: Right ureteral stent placed at 12:35 for decompression; purulent urine drained and specimen sent from renal pelvis. Patient received approximately 2.1 L total balanced crystalloid in the initial resuscitation and continues low-dose norepinephrine. BP and mentation have improved, but ongoing ICU monitoring is required.

Assessment: Urinary source septic shock due to obstructing ureteral stone; acute kidney injury is improving after drainage and perfusion support. Lactate remains elevated at 2.6, lower than 4.1. Cultures and susceptibilities are pending.

Plan: Continue ordered antimicrobial therapy with renal dose review, follow cultures and narrow when appropriate, monitor stent drainage and urine output, and titrate pressor based on perfusion and MAP. Repeat lactate and kidney function as ordered. Definitive stone treatment follows recovery from acute infection per urology.

Signed: Camille Price, MD / Nadia Shah, MD · 14:55

Nursing note

14:45–15:00 · A. Rivera, RN · ICU

Patient states, “I know where I am now.” Oriented × 4, follows commands, skin warmer, capillary refill ~2 seconds. BP 108/66 on norepinephrine 0.03 mcg/kg/min; HR 104, RR 21, lungs clear. Urine output 90 mL in the last hour after stent placement; light pink urine without clots documented. Handoff confirms 2.1 L balanced crystalloid received. Lactate 2.6, creatinine 1.4. Continuing frequent BP, IV site, respiratory, urinary drainage, and neurologic checks; reported improvement and residual pressor requirement to ICU provider.

Vital signs

Measure	08:10	10:30	14:45	Reference / goal
Temperature	39.1°C	39.3°C	37.8°C / 100.0°F	Trend fever
Heart rate	118	132	104/min	60–100/min
Respirations	24	28	21/min	12–20/min
Blood pressure	96/58 (MAP ~71)	82/48 (MAP ~59)	108/66 (MAP ~80) on pressor	Ordered shock target; wean as appropriate
SpO₂	96% RA	94% RA	96% RA	Assess clinically
Mental status	Slower responses	Disoriented to date	Oriented × 4	Baseline oriented × 4
Urine output	Not quantified	20 mL / 2 hr	90 mL / last hr	Trend with renal status

Focused assessment

Neuro: Alert and oriented × 4; attention improved.
Cardiovascular: Warm hands, capillary refill ~2 seconds; BP supported by low-dose norepinephrine.
Respiratory: Lungs clear, RR 21, no distress after initial fluid resuscitation.
GU / renal: Ureteral stent in place; 90 mL urine output in last hour, light pink without clots.
Skin: Mottling resolved; IV site intact.

Labs

Test	08:10	10:30	14:45	Reference*
WBC	17.2 H	20.1 H	18.6 H	4.0–11.0 ×10³/µL
Lactate	2.4 H	4.1 H	2.6 mmol/L H	0.5–2.0 mmol/L
Creatinine	1.4 H	1.7 H	1.4 mg/dL H	0.6–1.2 mg/dL; baseline ~0.9
BUN	27 H	32 H	29 mg/dL H	7–20 mg/dL
Sodium	134 L	133 L	135 mmol/L	135–145 mmol/L
Potassium	4.2	4.3	4.1 mmol/L	3.5–5.0 mmol/L
Glucose	186 H	202 H	174 mg/dL H	70–99 mg/dL fasting†
Urinalysis	LE +, nitrites +, >50 WBC/hpf	Not repeated	Not repeated	Negative; 0–5 WBC/hpf
Blood / urine cultures	Collected	Pending	Pending; renal pelvis specimen collected	Follow final result and susceptibility

*Illustrative ranges. †The fasting glucose interval is not a treatment target for this acutely ill patient.

Diagnostics

CT result from 10:50: obstructing 6 mm right proximal ureteral stone with moderate hydronephrosis. Urology performed cystoscopy and right ureteral stent placement at 12:35, achieving drainage of purulent urine. Definitive stone removal is deferred until infection is controlled.

Provider orders

Continue norepinephrine per ICU protocol and reassess MAP, mentation, capillary refill, and urine output as it is weaned.
Continue piperacillin–tazobactam per pharmacy-adjusted schedule; review cultures for de-escalation when final identification and sensitivities return.
Trend urine output and stent drainage; report fever recurrence, clots, decreased output, flank pain, or new instability.
Repeat lactate and metabolic panel per ICU plan; avoid reflexive additional fluid solely to normalize lactate.
Urology follow-up for definitive stone management after acute infection resolves.

MAR · Medication administration

Medication / fluid	Order	Given / status	Nursing consideration
Balanced crystalloid	Initial resuscitation ~2,100 mL	Completed by 11:25	Reassess before additional fluid.
Piperacillin–tazobactam	4.5 g IV initial dose; later dosing per pharmacy	Initial dose completed 11:28	Check cultures and renal function.
Norepinephrine	Titrate to MAP order	0.03 mcg/kg/min at 14:45	BP supported; monitor IV site and wean per protocol.

Pause & decide · Evaluate outcomes

Question 1 · Evaluate outcomes Which findings show improvement? Which findings still require monitoring before calling the shock resolved?

Question 2 · Evaluate / generate solutions Cultures are still pending. What should the nurse anticipate in the next phase of care, and why should treatment not be stopped simply because the fever fell?

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Key takeaways

Trend the whole perfusion picture: MAP, mentation, capillary refill, lactate, and urine output.
Draw cultures promptly when feasible and give timely antibiotics; do not wait for final culture results to treat probable sepsis.
Persistent hypotension and hypoperfusion call for repeated assessment during fluid resuscitation and ordered vasopressor support.
An infected obstructed collecting system requires urgent drainage as source control.
Improvement after intervention does not equal resolution while pressors are needed and organ function remains abnormal.

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Jordan Ellis

Admission snapshot

Patient timeline

Notes

Vital signs

Focused assessment

Labs

Diagnostics

Provider orders

MAR · Medication administration

Pause & decide · Before the next timestamp

Notes

Vital signs

Focused assessment

Labs

Diagnostics

Provider orders

MAR · Medication administration

Pause & decide · Before the next timestamp

Notes

Vital signs

Focused assessment

Labs

Diagnostics

Provider orders

MAR · Medication administration

Pause & decide · Evaluate outcomes

Ready to compare your decisions?

Key takeaways

Clinical notebook

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