Sepsis Qs

B AND C

A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of a. nitroglycerine (Tridil). b. dobutamine (Dobutrex). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride).

ANS: A The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all consistent with the patient's diagnosis of cardiogenic shock.

14. Which information obtained by the nurse when caring for a patient who has cardiogenic shock indicates that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patient's serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patient has crackles throughout both lung fields. d. The patient's extremities are cool and pulses are weak.

Correct Answer: D Rationale: Hypothermia is an indication that the patient is in the progressive stage of shock. The other data are consistent with compensated shock.

16. The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a need for a change in therapy? a. The patient is restless and anxious. b. The patient has a heart rate of 134. c. The patient has hypotonic bowel sounds. d. The patient has a temperature of 94.1° F.

ANS: C Patients with neurogenic shock may have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.

16. When the charge nurse is evaluating the skills of a new RN, which action by the new RN indicates a need for more education in the care of patients with shock? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Decreasing the room temperature to 68° F for a patient with neurogenic shock d. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR

(D) Supplemental oxygen and airway management. The initial evaluation of any critically ill patient in shock should include assessing and establishing an airway, evaluating breathing (which includes consideration of mechanical ventilator support), and restoring adequate circulation.2 Adequate oxygenation should be ensured with a goal of achieving an arterial oxygen saturation of 90% or greater.

A 70-year-old man presents to the emergency de- partment with a 2-day history of fever, chills, cough, and right-sided pleuritic chest pain. On the day of admission, the patient's family noted that he was more lethargic and dizzy and was falling frequently. The patient's vital signs are: temperature, 101.5°F; heart rate, 120 bpm; respiratory rate, 30 breaths/min; blood pressure, 70/35 mm Hg; and oxygen saturation as measured by pulse oximetry, 80% without oxygen supplementation. A chest radiograph shows a right lower lobe infiltrate. What is the first step in the initial management of this patient? (A) Antibiotic therapy (B) β-Blocker therapy to control heart rate (C) Intravenous (IV) fluid resuscitation (D) Supplemental oxygen and airway management (E) Vasopressor therapy with dopamine

Correct answer: d Rationale: Adequate tissue perfusion in a patient with multiple-organ dysfunction syndrome is assessed by the level of consciousness, urine output, capillary refill, peripheral sensation, skin color, extremity skin temperature, and peripheral pulses.

The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are a. blood pressure, pulse, and respirations. b. breath sounds, blood pressure, and body temperature. c. pulse pressure, level of consciousness, and pupillary response. d. level of consciousness, urine output, and skin color and temperature.

D

The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a need for a change in therapy? a. The patient is restless and anxious. b. The patient has a heart rate of 134. c. The patient has hypotonic bowel sounds. d. The patient has a temperature of 94.1° F.

ANS: A Because patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patient's status

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. Skin cool and clammy c. Blood pressure of 92/56 mm Hg b. Heart rate of 118 beats/min d. O2 saturation of 93% on room air

ANS: A Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate.

1. A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate is 120 and the central venous pressure and pulmonary artery wedge pressure are low. Which of these orders by the health care provider will the nurse question? a. Give furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 150 mL/hr. c. Administer hydrocortisone (SoluCortef) 100 mg IV. d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr.

ANS: E, D, C, A, B The initial action for this hypotensive and hypoxemic patient should be to improve the oxygen saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before administration of antibiotics.

1. The health care provider prescribes these actions for a patient who has possible septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90%. In which order will the nurse implement the actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain blood and urine cultures. b. Give vancomycin (Vancocin) 1 g IV. c. Infuse vasopressin (Pitressin) 0.01 units/min. d. Administer normal saline 1000 mL over 30 minutes. e. Titrate oxygen administration to keep O2 saturation >95%.

Correct Answer: C Rationale: When fluid resuscitation is unsuccessful, administration of vasopressor drugs is used to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Dobutamine will increase stroke volume, but it would also further decrease SVR. Nitroprusside is an arterial vasodilator and would further decrease SVR.

10. A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of a. nitroglycerine (Tridil). b. dobutamine (Dobutrex). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride).

Correct Answer: B Rationale: The patient who has received chemotherapy is immune compromised, and placing the patient in a private room will decrease the exposure to other patients and reduce infection/sepsis risk. Administration of medications through the central line increases the risk for infection and sepsis. There is no indication that the patient is neutropenic, and restricting the patient to cooked and processed foods is likely to decrease oral intake further and cause further malnutrition, a risk factor for sepsis and shock. Insertion of an NG tube is invasive and will not decrease the patient's nausea and vomiting.

11. A patient who is receiving chemotherapy is admitted to the hospital with acute dehydration caused by nausea and vomiting. Which action will the nurse include in the plan of care to best prevent the development of shock, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction syndrome (MODS)? a. Administer all medications through the patient's indwelling central line. b. Place the patient in a private room. c. Restrict the patient to foods that have been well-cooked or processed. d. Insert a nasogastric (NG) tube for enteral feeding.

ANS: A Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate and should be initiated quickly as well.

15. A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104° F, and blood glucose 246 mg/dL. Which of these prescribed interventions will the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Infuse drotrecogin- (Xigris) 24 mcg/kg. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Titrate norepinephrine (Levophed) to keep mean arterial pressure (MAP) at 65 to 70 mm Hg.

ANS: B Since patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information also will be reported, but does not indicate deterioration of the patient's status.

17. When caring for a patient who has septic shock, which assessment finding is most important for the nurse to report to the health care provider? a. BP 92/56 mm Hg b. Skin cool and clammy c. Apical pulse 118 beats/min d. Arterial oxygen saturation 91%

ANS: D The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.

19. During change-of-shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which finding is most important for the nurse to report to the health care provider? a. Decreased bowel sounds b. Apical pulse 110 beats/min c. Pale, cool, and dry extremities d. New onset of confusion and agitation

Correct Answer: B Rationale: Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions are also appropriate and should be initiated quickly as well.

22. A patient who has just been admitted with septic shock has a BP of 70/46, pulse 136, respirations 32, temperature 104.0° F, and blood glucose 246 mg/dl. Which order will the nurse accomplish first? a. Start insulin drip to maintain blood glucose at 110 to 150 mg/dl. b. Give normal saline IV at 500 ml/hr. c. Titrate norepinephrine (Levophed) to keep MAP at 65 to 70 mm Hg. d. Infuse drotrecogin- (Xigris) 24 mcg/kg.

Correct Answer: A Rationale: In the early stages of septic shock, the cardiac output is high. The other hemodynamic changes would indicate that the patient had developed progressive or refractory septic shock.

23. A patient in compensated septic shock has hemodynamic monitoring with a pulmonary artery catheter and an arterial catheter. Which information obtained by the nurse indicates that the patient is still in the compensatory stage of shock? a. The cardiac output is elevated. b. The central venous pressure (CVP) is increased. c. The systemic vascular resistance (SVR) is high. d. The PAWP is high.

ANS: B Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patient's diagnosis and should be reported to the health care provider but does not indicate a need for a change in therapy.

23. Which information about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the heath care provider? a. The patient's heart rate is 108 beats/min. b. The patient is complaining of chest pain. c. The patient's peripheral pulses are weak. d. The patient's urine output is 15 mL/hr.

Correct Answer: C Rationale: The best data for assessing the adequacy of cardiac output are those that provide information about end-organ perfusion such as urine output by the kidneys. The low urine output is an indicator that renal tissue perfusion is inadequate and the patient is in the progressive stage of shock. The low BP, increase in pulse, and low-normal O2 saturation are more typical of compensated septic shock.

27. When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse? a. BP 88/56 mm Hg b. Apical pulse 110 beats/min c. Urine output 15 ml for 2 hours d. Arterial oxygen saturation 90%

D) Severe sepsis. The patient fulfills criteria for severe sepsis, defined as sepsis with evidence of organ dysfunction, hypoperfusion, or hypotension. SIRS is defined as an inflammatory response to insult manifested by 2 of the following: temperature greater than 38°C (100.4°F) or less than 36°C (96.8°F), heart rate greater than 90 bpm, respiratory rate greater than 20 breaths/min, and white blood cell count greater that 12 × 103/μL, less than 4 × 103/μL, or 10% bands. A diagnosis of sepsis is given if infec- tion is present in addition to meeting criteria for SIRS. Septic shock includes sepsis-induced hypotension (despite fluid resuscitation) along with evidence of hypoperfusion. MODS is the presence of altered organ function such that hemostasis cannot be maintained without intervention.1 This patient's lack of fluid resuscitation classifies him as having severe sepsis rather than septic shock.

A 70-year-old man presents to the emergency department with a 2-day history of fever, chills, cough, and right-sided pleuritic chest pain. On the day of admission, the patient's family noted that he was more lethargic and dizzy and was falling frequently. The patient's vital signs are: temperature, 101.5°F; heart rate, 120 bpm; respiratory rate, 30 breaths/min; blood pressure, 70/35 mm Hg; and oxygen saturation as measured by pulse oximetry, 80% without oxygen supplementation. A chest radiograph shows a right lower lobe infiltrate. This patient's condition can best be defined as which of the following? (A) Multi-organ dysfunction syndrome (MODS) (B) Sepsis (C) Septic shock (D) Severe sepsis (E) Systemic inflammatory response syndrome (SIRS)

Correct answer: b Rationale: Septic shock is the presence of sepsis with hypotension despite fluid resuscitation along with the presence of inadequate tissue perfusion. To meet the diagnostic criteria for sepsis, the patient's temperature must be higher than 100.9° F (38.3° C), or the core temperature must be lower than 97.0° F (36° C). Hemodynamic parameters for septic shock include elevated heart rate; decreased pulse pressure, blood pressure, systemic vascular resistance, central venous pressure, and pulmonary artery wedge pressure; normal or elevated pulmonary vascular resistance; and decreased, normal, or increased pulmonary artery pressure, cardiac output, and mixed venous oxygen saturation.

A 78-year-old man has confusion and temperature of 104° F (40° C). He is a diabetic with purulent drainage from his right heel. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/minute; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of: a. sepsis. b. septic shock. c. multiple organ dysfunction syndrome. d. systemic inflammatory response syndrome.

B

A patient who has just been admitted with septic shock has a BP of 70/46, pulse 136, respirations 32, temperature 104.0° F, and blood glucose 246 mg/dl. Which order will the nurse accomplish first? a. Start insulin drip to maintain blood glucose at 110 to 150 mg/dl. b. Give normal saline IV at 500 ml/hr. c. Titrate norepinephrine (Levophed) to keep MAP at 65 to 70 mm Hg. d. Infuse drotrecogin- (Xigris) 24 mcg/kg.

B

A patient who is receiving chemotherapy is admitted to the hospital with acute dehydration caused by nausea and vomiting. Which action will the nurse include in the plan of care to best prevent the development of shock, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction syndrome (MODS)? a. Administer all medications through the patient's indwelling central line. b. Place the patient in a private room. c. Restrict the patient to foods that have been well-cooked or processed. d. Insert a nasogastric (NG) tube for enteral feeding.

ANS: A Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well

A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Give acetaminophen (Tylenol) 650 mg rectally. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Start norepinephrine to keep systolic blood pressure above 90 mm Hg

C- Patients in septic shock require large amounts of crystalloid fluid replacement. Nitrates and β-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be).

A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient? a-Insulin infusion b- IV administration of epinephrine c- Aggressive IV crystalloid fluid resuscitation d- Administration of nitrates and β-adrenergic blockers

B Patients in septic shock require large amounts of fluid replacement. Nitrates and β-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be).

A patient's localized infection has progressed to the point where septic shock is now suspected. Which of the following is an appropriate treatment modality for this patient? A) Insulin infusion B) Aggressive fluid resuscitation C) Intravenous administration of epinephrine D) Administration of nitrates and β-adrenergic blockers

A

When caring for a patient in acute septic shock, what should the nurse anticipate? A. Infusing large amounts of IV fluids B. Administering osmotic and/or loop diuretics C. Administering IV diphenhydramine (Benadryl) D. Assisting with insertion of a ventricular assist device (VAD)

D- A patient with peritonitis is at high risk for developing sepsis. In addition, a patient with diabetes is at high risk for infections and impaired healing. Sepsis and septic shock are the most common causes of MODS. Individuals at greatest risk for developing MODS are older adults and persons with significant tissue injury or preexisting disease. MODS can be initiated by any severe injury or disease process that activates a massive systemic inflammatory response.

The nurse is assisting in the care of several patients in the critical care unit. Which patient is at greatest risk for developing multiple organ dysfunction syndrome (MODS)? a-22-year-old patient with systemic lupus erythematosus who is admitted with a pelvic fracture after a motor vehicle accident b-48-year-old patient with lung cancer who is admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia c-65-year-old patient with coronary artery disease, dyslipidemia, and primary hypertension who is admitted for unstable angina d-82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection

B- Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachypnea and tachycardia.

The nurse would recognize which clinical manifestation as suggestive of sepsis? a- Sudden diuresis unrelated to drug therapy b- Hyperglycemia in the absence of diabetes c-Respiratory rate of seven breaths per minute d-Bradycardia with sudden increase in blood pressure

B Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachycardia and tachypnea.

The nurse would recognize which of the following clinical manifestations as suggestive of sepsis? A) Respiratory rate of seven breaths per minute B) Hyperglycemia in the absence of diabetes C) Sudden diuresis unrelated to drug therapy D) Bradycardia with sudden increase in blood pressure

B- Clinical manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism.

When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? a- Increased serum albumin b- Decreased respiratory compliance c- Increased gastrointestinal (GI) motility d- Decreased blood urea nitrogen (BUN)/creatinine ratio

D Clinical manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism.

When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which of the following clinical manifestations of multiple organ dysfunction syndrome (MODS)? A) Increased gastrointestinal (GI) motility B) Increased serum albumin C) Decreased blood urea nitrogen (BUN)/creatinine ratio D) Decreased respiratory compliance

B Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of intravenous fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. VADs are useful for cardiogenic shock, not septic shock. Diphenhydramine (Benadryl) may be used for anaphylactic shock, but would not be helpful with septic shock.

When caring for a patient in acute septic shock, the nurse would anticipate A) Administering osmotic and/or loop diuretics. B) Infusing large amounts of intravenous fluids. C) Administering intravenous diphenhydramine (Benadryl). D) Assisting with insertion of a ventricular assist device (VAD).

A- Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. VADs are useful for cardiogenic shock not septic shock. Diphenhydramine (Benadryl) may be used for anaphylactic shock but would not be helpful with septic shock.

When caring for a patient in acute septic shock, what should the nurse anticipate? a- Infusing large amounts of IV fluids b- Administering osmotic and/or loop diuretics c- Administering IV diphenhydramine (Benadryl) d- Assisting with insertion of a ventricular assist device (VAD)

ANS: B Rationale: The 68-year-old woman has several risk factors. First she is an older adult, and immune function decreases with age. The greatest risk factor is that she has just had bowel surgery. Not only does major surgery further reduce the immune response, the bowel cannot be "sterilized" for surgery. Therefore the usual bacteria of the bowel have the chance to escape the site and enter the bloodstream when the bowel is disrupted.

Which newly admitted client does the nurse consider to be at highest risk for development of sepsis? A. 75-year-old man with hypertension and early Alzheimer's disease B. 68-year-old woman 2 days postoperative from bowel surgery C. 80-year-old community-dwelling man with no other health problems undergoing cataract surgery D. 54-year-old woman with moderate asthma and severe degenerative joint disease of the right knee

E) Vasopressor-dependent septic shock. An inappropriate cortisol response is not uncommon in patients with septic shock. Low-dose IV corticosteroids (hydrocortisone 200-300 mg/day) are recommended

Which of the following is an indication for using corticosteroids in septic shock? (A) Acute respiratory distress syndrome (ARDS) (B) Necrotizing pneumonia (C) Peritonitis (D) Sepsis responding well to fluid resuscitation (E) Vasopressor-dependent septic shock

(D) Continuous infusion at low doses reduces the catecholamine infusion requirement. Vasopressin is a peptide synthesi zed in the hypothalamus and released from the posterior pituitary. Vasopressin produces a wide range of physiologic effects, including blood pressure maintenance. Acting through vascular V1receptors, the endogenous hormone directly induces vasoconstriction in hypotensive patients but does not significantly alter vascular smooth muscle constriction in humans with normal blood pressure. Landry and colleagues8 demonstrated that patients with septic shock had inappropriately low levels of serum vasopressin compared with patients with cardiogenic shock, who had normal or elevated levels. In addition, they demonstrated that supplementing a low-dose infusion of vasopressin in septic shock patients allowed for the reduction or removal of the other catecholamine vasopressors. This was seen de- spite a reduction in cardiac output. Although these results were duplicated in subsequent studies, none evaluated outcomes such as length of stay or mortal- ity until recently. A randomized double-blind study comparing vasopressin versus norepinephrine for the treatment of septic shock demonstrated no dif- ference in 28-day mortality between the 2 treatment groups.9 Subgroup analysis of patients with severe septic shock, defined as requiring 15 μg/min of norepinephrine or its equivalent, also did not demonstrate a mortality benefit. However, patients with less severe septic shock (ie, requiring 5-15 μg/min of norepinephrine) experienced a trend toward lower mortality when treated with low-dose (0.01-0.03 U/min) vasopressin.

Which of the following is true of vasopressin in septic shock? (A) Continuous infusion at low doses improves 28-day overall mortality (B) Continuous infusion at low doses improves mortality in patients with severe septic shock (C) Continuous infusion at low doses increases cardiac output (D) Continuous infusion at low doses reduces the catecholamine infusion requirement

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Suggested Responses: 1. What risk factors does this patient have for sepsis? Risk factors include older age, diabetes mellitus, poor mobility and self-care problems, a known urinary tract infection within the past 30 days, and an open skin area on a lower extremity. 2. What manifestations does she have that are consistent with sepsis and systemic inflammatory response syndrome (SIRS)? Manifestations include elevated temperature, a heart rate of more than 90 beats/min, a respiratory rate greater than 20 breaths/min, a blood glucose level above 120 mg/dL, a recent known infection, decreasing oxygen saturation, and confusion. 3. What assessment should you perform immediately? Assess the color of her skin and mucous membranes, capillary refill, and capnography. Obtain an order for a serum lactate level and a complete blood count with differential. Also obtain an order to insert a Foley catheter for accurate urine output assessment. 4. What would be the most likely source of infection? The two most likely sources of infection are the leg wound (even though the red area is adjacent to the scrape, it is an indication of cellulitis) and the urinary tract. 5. Should you express concern about the possibility of sepsis and SIRS to the emergency department intensivist? Why or why not? Absolutely; this patient meets multiple criteria for sepsis with SIRS and she is older. Her condition could worsen rapidly to severe sepsis and multiple organ dysfunction syndrome (MODS). She needs immediate intervention to save her life.

p. 825, Patient-Centered Care; Evidence-Based Practice The patient is an 82-year-old woman who has been a resident in an extended-care facility for the past year because of poor mobility and self-care problems. Today she is brought to the emergency department because she does not recognize her son and does not know where she is. She completed drug therapy for a urinary tract infection 1 week ago. Her skin is thin, and she has many bruises. In addition, she has a healing wound on her left shin, which her son tells you occurred 3 days ago when she scraped the area trying to get out of bed alone. The skin immediately surrounding the wound appears normal; however, about 3 inches to the right of the wound the skin is red, firm, and warm to the touch. These are her vital signs: T, 100.8 F (38.2 C); P, 112 beats/min; R, 24 breaths/min; BP, 118/80; SpO2, 92%. Oxygen at 3 L/min is applied until the neurologist can evaluate her, and an IV with normal saline is started at 100 mL/hr. Her son is concerned because she was given her oral antidiabetic drug this morning (5 hours ago) but has not eaten breakfast or lunch. When you check her blood glucose level, it is 131 mg/dL. When you assess her 15 minutes later, her oxygen saturation is 90%. 1. What risk factors does this patient have for sepsis? 2. What manifestations does she have that are consistent with sepsis and systemic inflammatory response syndrome (SIRS)? 3. What assessment should you perform immediately? 4. What would be the most likely source of infection? 5. Should you express concern about the possibility of sepsis and SIRS to the emergency department intensivist? Why or why not?