The aim of this assignment is to critically discuss the nursing assessment individualised care and nursing interventions of the acutely ill patient. The patient discussed developed severe sepsis due to a urinary tract infection and her condition deteriorated during the recovery process in the nurse’s care. Lovick (2009) defines sepsis ‘as a known or suspected infection accompanied by evidence of two or more of the SIRS criteria’. SIRS is outlined as a ‘systemic inflammatory response’ consisting of two or more of the following symptoms ‘temperature >38 degrees Celsius or 90 beats per minute, respiratory rates greater than 20 breaths per minute and white blood count higher than 12,000 cells per microliter or lower than 4000 cells per
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Measurement of a patient’s level of consciousness is an important task to be carried out because altered consciousness can have an adverse effect on a patient’s airway this is stressed by Steen (2010) who explains that ‘worsening conscious level could be at risk of airway obstruction and loss of gag reflex’. To ensure that the decreased level of consciousness was not due to hypoglycaemia, Mrs Smith’s blood sugars were tested. A finger was cleaned using cotton wool, was pricked and the blood was tested. The blood sugars were recorded as 5.4 within the normal parameters of 3.9-6.9. Therefore hypoglycaemia was not the cause of the patient’s altered level of consciousness. The nurse also used the numerical pain scale to assess Mrs Smith’s discomfort. The patient reported her pain as 7/10 and complained of soreness in the lower abdomen.
When addressing exposure, the nurse carried out a head to toe assessment of Mrs Smith. Sepsis may be apparent by inflamed wounds or red swollen cannula sites. Mrs Smith had no skin breaks or wounds and triple care cream was applied regularly to prevent skin breakdown. No IV cannulas were present on the patient, thus a cannula site was not the cause of infection for Mrs Smith. The patient’s temperature was recorded as 38.3OC, this was a huge deviation from the normal temperature range as per St.