Problem
Background on my patient -Janis Jordan, a 78 year old female was admitted to the emergency department at 0500 with urosepsis. Patient also has a history of heart failure and diabetes. Patient is currently diagnosed with UTI. Difficulty in breathing, all vitals were raised. Temperature 100.6 degrees Fahrenheit, respiratory rate is 32, O2 saturation 85% oxygen flow rate: 6 L/min. Patient states she doesn't feel good and feels cold when asked about her pain levels. Started on IV and Levofloxacin was administered in the ER. Manifestation of heart failure was shown by pitting edema, weak peripheral pulses, neck vein distention, and crackles in the lungs. Dark cloudy urine was seen with low output. Patient is at fall risk because she fell from the bed which caused hip fracture. Admitting diagnosis is urosepsis which is defined as sepsis caused by UTI (extreme reaction to infection). Patient lives alone (ATI 2019).
• I need help with coming up with two nursing problems the first one I came up with was hyperthermia due to urosepsis as evidenced by increase body temperature. What would be three interventions a nurse can do during her shift to help with this issue?
• What would be a second problem this patient would have? Something maybe related to manifestation of heart failure? And what would be three interventions a nurse can do during her shift to help.