The nurse is caring for a patient with a large bore catheter for total parenteral nutrition. Which of the following would indicate to the nurse that the patient might be experiencing catheter related sepsis?
1. heart rate 90 beats per minute and regular
2. chills and fever when hanging a new infusion bag
3. blood pressure 138/88 mm Hg
4. urine output 50 cc/hour
2
Rationale: Signs and symptoms of catheter related sepsis include: sudden onset of fever, rigors, or chills that coincide with parenteral infusion; erythema, swelling, tenderness, or purulent drainage from the catheter site; sudden temperature elevation that resolves on catheter removal; leukocytosis; sudden glucose intolerance that may occur up to 12 hours before temperature elevation; and bacteremia/septicemia/septic shock. Heart rate of 90 beats per minute and regular is not an indication of catheter related sepsis. A blood pressure of 138/88 mm Hg is not an indication of catheter related sepsis. Urine output of 50 cc/hour is a normal urine output.
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