Which set of assessment data is consistent for a patient with severe infection that could lead to system failure?
a. Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours
b. BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours
c. BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours
d. BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours
ANS: B
The patient with severe infection presents with low BP and compensating elevations in pulse to move lower volumes of blood more rapidly and respiration to increase access to oxygen. Urine output decreases to counteract the decreased circulating blood volume and hypotension. These vital signs are all too low: Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours. The patient with severe infection does have a low BP, but the pulse and respiratory rate increase to compensate. This data is all within normal limits: BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours. This set of data reflects an elevated BP with a decrease in pulse and respiratory rates along with normal urine output: BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours. None of these is a typical response to severe infection.
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