NGN case study
Older adult with pneumonia and new confusion
A 78-year-old client is brought to the emergency department by their daughter for a worsening cough and new confusion. The nurse reviews the client's record.
Client record
Nurse's Notes
1400: History of type 2 diabetes and hypertension. The daughter reports a productive cough for 3 days and new confusion since this morning; the client is normally fully oriented. The client is now oriented to person only. Skin warm and dry. Crackles in the right lower lobe. Capillary refill 4 seconds. The client says they feel "very tired" and has had little to eat or drink. The daughter says the client last urinated early this morning.
Vital Signs
| Time | Temp | HR | RR | BP | SpO2 |
|---|---|---|---|---|---|
| 1400 | 39.2°C (102.6°F) | 122/min | 28/min | 88/52 mm Hg | 89% on room air |
Laboratory Results
| Test | Result | Reference range |
|---|---|---|
| WBC | 18,500/mm³ | 5,000–10,000/mm³ |
| Lactate | 4.2 mmol/L | 0.5–2.0 mmol/L |
| Creatinine | 1.8 mg/dL | 0.6–1.2 mg/dL |
| Glucose | 248 mg/dL | 70–110 mg/dL |
| Sodium | 144 mEq/L | 135–145 mEq/L |
Orders
- Oxygen to keep SpO2 at 92% or higher
- Blood cultures ×2, drawn before antibiotics
- Lactate now and repeat in 2 hours
- 0.9% sodium chloride 30 mL/kg IV bolus
- Ceftriaxone 1 g IV and azithromycin 500 mg IV after cultures are drawn
- Chest x-ray
- Indwelling urinary catheter; strict intake and output
- Acetaminophen 650 mg PO/PR every 6 hours as needed for temperature above 38.3°C
Questions
Question 1 of 6
Recognize cues. Highlight the findings in the nurse's note that suggest inadequate tissue perfusion.
Select the findings that apply.
Answer and rationale
- Now oriented to person only; normally fully oriented.
- Capillary refill 4 seconds.
- Last urinated early this morning.
Brain (mentation), skin (capillary refill) and kidneys (urine output) are the bedside windows into perfusion. All three are abnormal here.
Question 2 of 6
Analyze cues. For each finding, indicate whether it is consistent with pneumonia, sepsis, or both. Each row may have more than one answer.
Choose for each row.
| Item | Pneumonia | Sepsis |
|---|---|---|
| Crackles in the right lower lobe | ||
| Lactate 4.2 mmol/L | ||
| Blood pressure 88/52 mm Hg | ||
| Productive cough | ||
| WBC 18,500/mm³ | ||
| Temperature 39.2°C |
Answer and rationale
- Crackles in the right lower lobe: Pneumonia
- Lactate 4.2 mmol/L: Sepsis
- Blood pressure 88/52 mm Hg: Sepsis
- Productive cough: Pneumonia
- WBC 18,500/mm³: Pneumonia, Sepsis
- Temperature 39.2°C: Pneumonia, Sepsis
Pneumonia is the source; sepsis is the dysregulated systemic response with organ dysfunction (hypotension, high lactate, confusion, rising creatinine).
Question 3 of 6
Prioritize hypotheses. Complete the sentence.
Choose the option that best completes each blank.
The client is at highest risk for developing , as evidenced by the client's .
Answer and rationale
The client is at highest risk for developing septic shock, as evidenced by the client's blood pressure of 88/52 mm Hg and lactate of 4.2 mmol/L.
Septic shock is the most immediate threat to life and drives the next actions.
Question 4 of 6
Generate solutions. Which actions should the nurse take now? Select all that apply.
Answer and rationale
- A. Apply oxygen to keep SpO2 at 92% or higher
- B. Draw blood cultures before giving antibiotics
- C. Start the 0.9% sodium chloride 30 mL/kg bolus
- D. Give IV antibiotics after cultures are drawn, within the first hour
These are the hour-1 sepsis bundle elements: lactate, cultures before antibiotics, broad-spectrum antibiotics, 30 mL/kg crystalloid for hypotension or lactate of 4 or higher, plus oxygen for hypoxemia.
Question 5 of 6
Take action. Which order should the nurse implement first?
Answer and rationale
A. Apply oxygen to keep SpO2 at 92% or higher
With an SpO2 of 89% and an RR of 28, breathing is the first priority, and applying oxygen takes seconds. Cultures, fluids and antibiotics follow right away.
Question 6 of 6
Evaluate outcomes. Three hours later the nurse reassesses the client. For each finding, indicate whether treatment has been effective or not effective.
Choose for each row.
| Item | Effective | Not effective |
|---|---|---|
| Blood pressure 104/64 mm Hg (MAP about 77) | ||
| Repeat lactate 1.9 mmol/L | ||
| Urine output 15 mL/hr for the last 2 hours | ||
| Heart rate 98/min | ||
| SpO2 95% on 2 L/min nasal cannula |
Answer and rationale
- Blood pressure 104/64 mm Hg (MAP about 77): Effective
- Repeat lactate 1.9 mmol/L: Effective
- Urine output 15 mL/hr for the last 2 hours: Not effective
- Heart rate 98/min: Effective
- SpO2 95% on 2 L/min nasal cannula: Effective
Most indicators are improving, but persistent oliguria needs follow-up: it may point to acute kidney injury or a need for further resuscitation.