When caring for a client with sepsis, the nurse recognizes that which of the following indicates a progression to severe sepsis? Select all that apply
1. Client requires intubation and mechanical ventilation for respiratory failure
2. Blood pressure of 80/42 after 4 liters of fluid have been given
3. Hematuria, epistaxis, and oozing from central venous catheter site
4. WBC count of 4000 cells/cubic millimeter
5. Urine output of 40 to 60 milliliters per hour
1. Client requires intubation and mechanical ventilation for respiratory failure
2. Blood pressure of 80/42 after 4 liters of fluid have been given
3. Hematuria, epistaxis, and oozing from central venous catheter site
Rationale: Client requires intubation and mechanical ventilation for respiratory failure. Severe sepsis is defined as the presence SIRS with hypotension/shock, a confirmed infection, and single or multiple organ failure. Inability to manage maintenance respiratory functions is consistent with a worsening condition. Blood pressure of 80/42 after 4 liters of fluid have been given. Continuing hypotension after the administration of treatment indicates a continuation of responses. Hematuria, epistaxis, and oozing from central venous catheter site. Coagulopathy may be a manifestation of worsening sepsis. WBC count of 4000 cells/cubic millimeter. A WBC count of 4000 is normal. Urine output of 40 to 60 milliliters per hour. Urine output of 40 to 60 ml/hour (or 0.5 ml/kg/hour) is normal.
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