Deteriorating Patient With Sepsis on a Busy Ward
Ms. Lindqvist, 54, was admitted 2 days ago with cellulitis of the left leg and is on IV cefazolin. At 14:00 the aide reports she 'seems confused.' You find her agitated and pulling at her lines. Temperature 38.9 C, heart rate 122/min, blood pressure 88/52 mmHg, respiratory rate 26/min, SpO2 93% on room air. Capillary refill 4 seconds, urine output 15 mL over the last 3 hours, and the left calf is now dusky and more tender. Lactate drawn an hour ago is pending. The ward has one other nurse and 12 patients; the intensivist is in another building.
1. Recognize and act: what is your interpretation and first-hour sequence?
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Interpretation: This is likely sepsis with possible progression to septic shock from a worsening soft-tissue infection. New confusion, fever, tachycardia, hypotension, tachypnea, delayed capillary refill, and oliguria meet multiple red flags. The dusky, tender calf suggests expanding infection or necrotizing process and warrants urgent surgical evaluation.
First-hour sequence (prioritized):
- Call for help - activate rapid response and assign the aide or clerk to bring the emergency cart and call the intensivist.
- Position supine with legs elevated, apply oxygen to keep SpO2 at least 94%, and start continuous monitoring.
- Establish a second IV and begin isotonic fluid bolus per sepsis protocol as ordered (commonly 30 mL/kg), reassessing blood pressure and lung sounds.
- Draw repeat lactate and blood cultures before or alongside antibiotics if not already done.
- Give broad-spectrum antibiotics promptly; escalate beyond cefazolin per order.
- Insert a urinary catheter to measure output and monitor hourly.
- Prepare for vasopressors and possible transfer.
Delegate vitals, urine measurement, and documentation to the second nurse while you manage airway, fluids, and communication. Reassess after each bolus.
2. How do you manage the competing demands of 12 other patients and document your escalation?
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Triage the competing demands: The deteriorating patient takes priority. Use the second nurse for the other 11 patients, asking them to do a quick safety round and report any unstable patient. Ask the charge nurse or house supervisor for relief staffing and to cover your other assignments. Delegate only tasks within the aide's scope (vitals, transport, supplies).
Structured handoff: Give the covering nurse a concise report of your other patients' key risks so nothing is missed.
Documentation: Record time-stamped findings, the rapid response activation, who was notified, orders received, interventions (oxygen, fluids, antibiotics, catheter), and the patient's response. Note the pending lactate and the calf change. If the intensivist is delayed, document the escalation to the supervisor and any further calls. Avoid retrospective charting; document in real time as able.
After stabilization: File an incident or escalation note if transfer was delayed, and debrief with the team. Identify system issues (single nurse coverage, off-site intensivist) and raise them through the quality channel.