SBAR Paper on Urosepsis and Dehydration

Running head: SBAR: UROSEPSIS AND DEHYDRATION 1
SBAR: Urosepsis and Dehydration
Z1650675
Northern Illinois University
March 17, 2015

UROSEPSIS AND DEHYDRATION 2
Analysis
Urosepsis
Pathophysiology. Urosepsis is a severe infection originating from the urogenital tract
that causes a systemic, inflammatory response (Kalra & Raizada, 2009).
The urinary tract consists of the upper portion (kidneys and ureters) and lower portion
(bladder and urethra). The kidneys produce urine at a continuous rate of more than 0.5 mL/kg of
body weight per hour. Urine flows from the kidneys through the ureters and into the bladder,
which stores and expels urine via the urethra (Andersson & Michel, 2011, p. 2).
Urosepsis begins when pathogenic bacteria invade the urogenital tract. According to a
study conducted in 2002, Escherichia coli (E. coli) was the most prominent organism found in
61% of cases of urosepsis. Nevertheless, these pathogens interact with the host’s immune
system cells (e.g., macrophages, neutrophils, endothelial cells) causing an inflammatory reaction,
which leads to cellular damage and potential death. For instance, when endothelial cells are
affected, decreased blood pressure (hypotension) occur as a result of decreased blood vessel tone
and increased permeability (Wagenlehner et al., 2013).
Wagenlehner et al. (2013) state that a majority of patients survive this initial phase;
however, the subsequent phase has a greater mortality risk. The patient enters an
immunosuppressive state due to his/her dysfunctional immune cells. Other body systems are
affected, such as the coagulation system potentially causing a severe disorder, disseminated
intravascular coagulation (DIC). According to Levi and Schmaier (2014), DIC is characterized
by the formation of blood clots throughout the body, which can inhibit vital blood flow to organs
and cause them to dysfunction.

Risk Factors. Urosepsis is often a result from a complicated urinary tract infection
(UTI), which occurs with the presence of predisposing risk factors, such as a structurally
abnormal or dysfunctional urinary tract, an obstruction to urine flow, or a suppressed immune
system. An uncomplicated UTI in contrast occurs in an otherwise healthy patient (Kalra &
Raizada, 2009). Kalra and Raizada (2009) set examples of a structurally abnormal or
dysfunctional urinary tract in Appendix A. According to Wagenlehner et al. (2013), the most
common cause is an obstruction to the free flow of urine in the upper urinary tract, which can be
due to a ureteral stone, tumor, or structural anomalies.
Those at increased risk for urosepsis are the elderly, diabetics and immunosuppressed
patients (i.e., patients with AIDS, on a chemotherapy drug regimen, etc.). According to a study
conducted in 2003-2004, there was a 10% prevalence rate of hospital-acquired UTIs with
urosepsis occurring in one of ten of those identified cases. Therefore, these findings signify a
correlation between urosepsis and developing a UTI in the hospital (Kalra & Raizada, 2009).
Clinical Manifestations. Urosepsis may present as the hallmark signs of systemic
inflammatory response syndrome (SIRS), which includes the following: fever, increased heart
rate (tachycardia), increased respiration rate (tachypnea), and an abnormal white blood cell count
(leukocytes). These signs are not necessary for diagnosis, but they are considered a warning of
urosepsis (Kalra & Raizada, 2009).
The early manifestations of urosepsis can embody ‘warm shock’ with warm extremities,
low blood pressure, and bounding pulse. The later manifestations signifies ‘cold shock’ with
cold extremities and further loss in blood pressure. Further disease progression can potentiate
into respiratory distress, DIC, and multi-organ failure with kidney and liver dysfunction (Kalra &
Raizada, 2009).

Diagnostic Testing. Kalra and Raizada (2009) explain that the diagnostic evaluation
comprises a history, physical exam, urine and blood analysis and culture, and imaging tests. The
history is critical in order to deduce the underlying cause and should inquire about previous
infections, antibiotic use, and description of symptoms. According to Wagenlehner et al. (2013),
the physical assessment will reveal fever or hypothermia, hypotension, tachypnea, tachycardia,
altered mental status, high blood glucose in absence of diabetes, and edema.
Kalra and Raizada (2009) state that a urine culture is the initial step towards diagnosis;
however, a positive result does not confirm urosepsis except for the actual presence of bacteria in
the urine. A blood culture will be required prior to the start of empirical antibiotic therapy and
will identify whether bacteria has spread into the patient’s blood stream. Furthermore, a blood
analysis will reveal whether the body’s immune system cells (i.e., white blood cell count) are
abnormal and attempting to fight off the infection (Wagenlehner et al., 2013). Kalra and Raizada
(2009) clarify that the most precise diagnostic imaging tests of urosepsis are CT scans and MRI
tests. CT scans, more specifically, have an increased sensitivity for obstructive stone detection
(Dagli & Ramchandani, 2011). Wagenlehner et al. (2013) list the universally accepted
diagnostic criteria for sepsis in Appendix B.
Treatments. Urosepsis is a life-threatening illness with a mortality rate as high as 20-
40%. Thus, the early initiation of therapy is critical, and is associated with more prosperous
patient outcomes (Wagenlehner et al. (2013).
According to Kalra and Raizada (2009), the focus of initial management includes
maintaining the patient’s blood pressure and oxygenation within normal limits. If these vital
signs are abnormal, the administration of fluid expanders and oxygen is necessitated. Fluid

expanders, such as a crystalloid (e.g., normal saline), should be given at 500-1000 mL over 30
minutes for hypovolemia (Dellinger et al., 2004, p. 862).
Once the patient is stabilized, investigation of the underlying cause follows with
diagnostic imaging tests. Then, immediate control and/or extraction is needed when the
problematic factor is identified. Procedures typically consist of two stages: low-level invasive
treatment (e.g., percutaneous nephrostomy) for pain relief and urinary drainage, then definitive
removal of the underlying cause (e.g., ureteral stone) (Wagenlehner et al., 2013).
Antimicrobials are critical in the therapeutic regimen of severe infections; however, these
drugs are not initiated until there is a reduction in bodily temperature or control and elimination
of the primary cause. For empirical antibiotic therapy, E. coli infections can be treated with
piperacillin and tazobactam for a duration of three to five days (refer to Appendix C for further
drug information on piperacillin/tazobactam). Overall, early detection and treatment of urosepsis
is crucial and will significantly lower the patient’s mortality risk (Wagenlehner et al., 2013).
Nursing Management. The goals of nursing care are for the patient to demonstrate
signs of adequate perfusion and be rid of infection. Monitoring of the hemodynamic parameters
(e.g., heart rate and blood pressure) and serum lactate levels will ensure that the patient is
maintaining adequate tissue perfusion and oxygenation (Perrin, 2008).
The patient free of infection will show signs as evidenced by negative cultures (e.g.,
blood, sputum, urine) and normal temperature. It is the nurse’s responsibility to obtain the
cultures. In addition, the nurse will need to administer the initial broad-spectrum antibiotics,
then switch to a narrow-spectrum antibiotic once the specific organism has been revealed by
cultures (Perrin, 2008).

Dehydration
Pathophysiology. Dehydration is a condition in which the body does not contain an
adequate amount of water, or has a negative fluid balance. The type varies depending on the
sodium concentration in the blood stream (Braun & Anderson, 2007, p. 212). In Appendix D
Braun and Anderson (2007) outline the criteria for the different classifications: hyponatremia,
isonatremia, and hypernatremia.
The amount of sodium in the blood is significant since it reveals the fluid loss
composition and will have a different pathophysiologic impact. For instance, isonatremic
dehydration signifies an equal proportion of sodium and water loss. Hypernatremic dehydration
shows an abnormally increased level of sodium in the blood versus water; therefore, the body
seeks equilibrium by transporting fluids from the extravascular space into the intravascular space
(blood vessels). Hyponatremic dehydration occurs vice versa to hypernatremic dehydration.
The most prominent is isonatremic dehydration, which is found in 80% of cases (Huang,
Anchala, Ellsbury, & George, 2014).
The potential causes of dehydration includes a decreased fluid intake, excess fluid output,
and/or fluid shifts between body compartments (e.g., ascites, burns, and sepsis). Excess fluid
output occurs through the kidneys (i.e., urination), gastrointestinal tract (i.e., diarrhea), and
insensible means. (Braun & Anderson, 2007, p. 212).
Risk Factors. Those at increased risk for dehydration include young children, older
adults, and diabetics. Young children are at risk since they have a larger volume of bodily fluids
and immature kidneys. In addition, they might be unable to independently meet their own needs
in terms of hydration (Huang et al., 2014).

Clinical Manifestations. Huang et al. (2014) classify the manifestations of dehydration
into mild, moderate, and severe forms as present in Appendix E. Abnormal signs of mild
dehydration consist of slight tachycardia and decreased urinary output. Moderate signs display
lethargy, capillary refill of two to four seconds, dry mucous membranes, tachycardia, orthostatic
hypotension, slow skin turgor, and decreased urine output (oliguria) (Huang et al., 2014).
Severe dehydration shows signs of obtunded levels of consciousness, capillary refill
greater than four seconds, parched mucous membranes, very increased heart rate, oliguria, or no
urine output (anuria). The best indicators are the capillary refill time, respiratory rate and
pattern, and skin turgor. With worsening progression of dehydration, hypovolemic shock may
develop and lead to organ failure and/or death (Huang et al., 2014).
Diagnostic Testing. Huang et al. (2014) state that there are no definitive diagnostic tests
for dehydration. According to Braun and Anderson (2007), the diagnostic investigation involves
a recent history, evaluation of manifestations, and laboratory testing. The recent history can
serve as the basis of diagnosis and help identify the cause (e.g., malnutrition) and severity. The
physical assessment will distinguish the severity of dehydration based on certain clinical
manifestations (p. 213). Huang et al. (2014) clarify the clinical manifestations based on mild,
moderate, and severe forms of dehydration in Appendix E.
Typically, results of a blood test identifies an increase in blood substances, such as
hemoglobin, hematocrit, glucose, albumin, and various electrolytes. These findings occur due to
body water loss while substances in the blood remain (Ignatavicius & Vorkman, 2015, p. 157).
However, the serum sodium level will vary depending on the type of dehydration (e.g.,
hyponatremia, isonatremia, hypernatremia). The blood analysis also evaluates the kidney’s
perfusion by determining the blood urea nitrogen (BUN) and serum creatinine levels, which will

be increased in dehydration. In addition, it can reveal a lack of tissue perfusion, which will show
an increase in lactic acid (Huang et al., 2014). Refer to Appendix F for the comparison of lab
values consistent with dehydration versus a normal, healthy adult.
Huang et al. (2014) state that the urine sample’s purpose is to identify the concentration
by measuring the specific gravity, which will be elevated; however, a urine sample is not always
an accurate test. A urinalysis can also evaluate the classification of dehydration by measuring
the urine’s sodium content (Braun & Anderson, 2007, p. 213).
Treatment. The focus of management is to identify and treat the underlying cause and
replace fluid loss. For mild to moderate dehydration, the administrations of oral rehydration
solutions (e.g., Rehydralyte) is necessitated. The patient should drink at least 300 mL/hr over a
four hour duration. The type of solution is significant since it must contain certain amounts of
glucose, sodium, and potassium. Clear liquids are ineffective since they often consist of
excessive carbohydrates and insufficient amounts of sodium (Huang et al., 2014).
Severe dehydration is treated in two phases: emergency management and deficit
replacement. The initial phase requires the immediate administration of an isotonic crystalloid
solution through an intravenous line. The following phase consists of replacing the fluid and
electrolytes and providing maintenance fluids (Huang et al., 2014).
Nursing Considerations. The goals of nursing management is to monitor and replenish
the patient’s fluid and electrolyte loss. The expected outcome is for the patient to maintain a
normal urinary output, normotensive blood pressure and heart rate, and normal skin turgor.
Therefore, ongoing assessments, interventions, and education will be needed to ensure a positive
outcome (Galanes & Gulanick, 2002).

Galanes and Gulanick (2002) state that accurate measurements of the patient’s intake and
output should be recorded and include all forms of output (i.e., blood, emesis, stool, and urine).
The patient should maintain a urinary output of at least 0.5 mL/kg of body weight per hour
(Andersson & Michel, 2011, p. 2). Therapeutic interventions include encouraging the patient to
drink the prescribed amount of fluids and offering different forms of liquids (e.g., popsicles,
gelatin, sports drinks). The patient should be informed of the importance of complying with the
prescribed fluid intake, causes of fluid loss, and how to prevent dehydration in the future
(Galanes & Gulanick, 2002).
Ureteral stone obstruction
The onset of symptoms occur when a ureteral calculus becomes too enlarged. The
prominent symptom is excruciating, intermittent pain that begins in the flank and radiates to the
groin. Other symptoms include complaints of lethargy, frequent urination, and difficulty/burning
upon urination (dysuria). The risk factors for stone development includes the following:
increased sodium consumption, lack of fluid intake, personal and/or family history, and limited
physical activity (White, Duncan, & Baumle, 2011, p. 1204).
Extracorporeal Shock Wave Lithotripsy
Extracorporeal shock wave lithotripsy (ESWL) utilizes high-intensity shock waves to
disintegrate calculi obstructions and enable their passage through urination (Schilling Mccann,
2002, p. 652). According to the National Guideline Clearinghouse (2010), when patients are pre-
medicated with midazolam (5 mg orally), 70% of patients reported pain relief during the
treatment. Refer to Appendix G for further drug information regarding midazolam. If necessary,
tramadol, which has been proven to be a safe and effective analgesic, may be given during the

procedure (refer to Appendix H for more drug information on tramadol). Post-treatment pain is
typically mild to moderate and oral analgesics (e.g. tramadol) can provide adequate relief
(National Guideline Clearinghouse, 2010). According to Schilling McCann (2002), after ESWL,
an indwelling urinary catheter should be inserted to help monitor the patient’s fluid balance and
urine characteristics. Blood-tinged urine and slight redness or bruising on the treated side is
normal for several days after the operation. The patient should be encouraged to ambulate and
increase fluid intake as ordered since this will aid in passage of calculi fragments (p. 653).
Situation
Good afternoon Dr. Kuchinski, my name is Michelle King and I am a nurse here on the
Medical/Surgical unit at NIU Hospital. I am calling in regards to your recently admitted patient,
19-year-old female, Amanda Grohl. She was admitted this afternoon at 1330 after her ESWL
treatment for further monitoring and care. She has no known allergies and is a full code.
During my admission history I found that she was diagnosed in the ED with urosepsis
due to an obstructive ureteral calculus. I am concerned that she is exhibiting signs of
dehydration, as evidenced by a heart rate of 110 bpm, supine blood pressure of 110/80, which
drops to 90/75 while sitting up, and respiration rate of 22 breaths per minute. On further
assessment, she had a capillary refill time of four seconds, slowed skin turgor, thready pulses on
palpation, and a urine output of 20 mL/hr with blood-tinged urine. The laboratory tests revealed
abnormal findings of increased blood glucose of 140 mg/dL, hemoglobin of 17 g/dL, hematocrit
of 54%, albumin of 55 g/L, BUN of 24 mg/dL, and lactic acid of 22 mg/dL.
Background

Amanda Grohl is a 19-year-old Caucasian female. She is living in an apartment in
DeKalb with her roommate. She is currently a full-time student at Kishwaukee College and is
unemployed. Amanda reported a family history of kidney stones on her father’s side of the
family. When asked about her daily hydration habits, the patient stated, “I try to avoid drinking
fluids, since I always have an urge to pee right after.” When asked about her recent nutrition
patterns, the patient stated, “I’ll admit I’ve been eating a lot of salty junk food.” The patient was
asked about the frequency of her physical activity and reported, “I haven’t done much physical
activity at all this year. I’ve just been feeling too tired for some reason.” The patient reported
the sudden, but intermittent onset of flank pain radiating to the groin (rated 10/10) since 1100
this morning. When asked about recent patterns in urination, the patient stated, “This past week
I had a hard time urinating and it would also burn. When my pain hit me like a brick wall, I just
couldn’t urinate at all!”
Amanda arrived to the Emergency Department (ED) at 1130 with complaints of lethargy
and severe flank pain radiating to the groin. She has no known allergies and is a full code. Her
admitting vital signs in the ED were temperature of 102.3 F, blood pressure 85/65 mmHg, heart
rate of 120 beats per minute, respiration rate of 24 breaths per minute, and oxygen saturation of
98% on three liters of oxygen. She located her pain at the right flank radiating to her groin. She
rated her pain 10/10 and described it as intermittent. She appeared agitated and was alert and
oriented to person, place, and time.
A fluid bolus of 0.9% normal saline was administered at 500 mL over 30 minutes in the
antecubital site, with a size 16-gauge catheter. The emergency physician ordered three liters of
oxygen through a nasal cannula in order to normalize her oxygen saturation levels above 94%.
The ED completed blood work with abnormal results identifying increases in white blood cell

count (13,000 mcL), calcium (12.0 mg/dL), creatinine (0.6 mg/dL), blood glucose (145 mg/dL),
and lactate (2 mmol/L). The blood culture was positive for E. coli. The imaging results from the
non-contrast CT scan was positive for a ureteral calculus. Amanda had a percutaneous
nephrostomy temporarily inserted for pain relief and urinary drainage. She received midazolam
(5 mg orally) prior to the ESWL treatment for anticipatory pain relief. Then, she was given
tramadol (25 mg PO) during the ESWL for further pain relief. She reported a reduction in pain
(2/10) throughout the procedure.
Amanda was admitted to the Medical/Surgical floor at 1330 for further monitoring and
postoperative care from the ESWL treatment.
Assessment
Amanda has been admitted into the Medical/Surgical unit since 1330 and her current vital
signs are: temperature of 98.9 F, heart rate 110 bpm, supine blood pressure of 110/80 rpm and
drops to 90/75 rpm while sitting up, respirations of 22 breaths per minute and oxygen saturation
is 100% on two liters of oxygen via nasal cannula. She is 56.7 kg (125 pounds) and is 162.5 cm
(5’ 4” tall). She appears lethargic, but she is oriented to person, place, and time. Her eyes
appear sunken with pupils that are reactive and appropriate to room light. She has a slowed skin
turgor and dry skin on palpation. She reports a dull pain of 3/10 at the right flank. The treatment
site (right flank) from the ESWL has slight petechiae and redness. On auscultation, her S1 and
S2 heart sounds were heard with a regular rhythm. In addition, her anterior and posterior lung
sounds on auscultation were clear bilaterally. Her breathing pattern appears regular and
unlabored and she reports no shortness of breath. Her bilateral radial pulses are thready with a
capillary refill time of four seconds. She has full range of motion of her extremities, equal
strength bilaterally, and no swelling or masses were palpated. She has an indwelling urinary

catheter and has a urine output of 20 mL/hr with blood-tinged urine. Abdomen is soft and flat
with bowel sounds active in all four quadrants.
The laboratory tests revealed abnormal findings of increased blood glucose of 140
mg/dL, hemoglobin of 17 g/dL, hematocrit of 54%, albumin of 55 g/L, BUN of 24 mg/dL, and
lactic acid of 22 mg/dL.
She has a left antecubital IV running with 3.375 g of Zosyn diluted in 200 mL of normal
saline over 30 minutes. The IV dressing is dry and intact with no signs of inflammation. At
1400 the patient received 25 mg of tramadol for pain of 3/10 in the right flank area. The patient
has been encouraged to ambulate and drink the prescribed amount of fluids (3-4 L/day) to help
the passage of calculi fragments. A diet low in sodium has been informed. The patient’s bed has
been placed in the lowest position, call light is within reach, and the patient is wearing non-slip
socks.
Recommendations
I am recommending a prescription of an oral rehydration solution, Rehydralyte, for
Amanda to drink at least 300 mL/hr over a four hour duration. This prescription is needed in
order to prevent further worsening of dehydration and replace her fluid deficit. The desired
outcome is for Amanda to have the following within normal limits: heart rate, respiration rate,
urinary output, and positional changes in blood pressure. I will call you back in an hour for an
update on whether she shows improvement from this treatment. Until then, I will continue to
monitor her vital signs and intake and output. In addition I will encourage her to drink the
prescribed amount of fluids. Is there anything else I can do for you at this time?

References
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Philadelphia, PA: Lippincott Williams & Wilkins.
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Appendix A
The following information provides examples of the various causes of urosepsis related to
abnormalities of the genitourinary tract.
Table 1: The Abnormalities (Structural and Functional) of the Genitourinary Tract that
Correlates with Urosepsis.
Obstruction Congenital:
 Ureteric or urethral strictures, phimosis,
ureterocele, polycystic kidney disease.
Acquired:
 Calculi, prostatic hypertrophy, tumors of
the urinary tract, trauma, and radiation
therapy.
Instrumentation Indwelling catheter, ureteric stent,
nephrostomy tube, urological procedures.
Impaired voiding Neurogenic bladder, cystocele, vesicoureteral
reflux.
Metabolic abnormalities Nephrocalcinosis, diabetes, azotemia.
Immunodeficiencies Patients on immunosuppressant drug or with
an abnormally low neutrophil count
(neutropenic).
(Kalra & Raizada, 2009)

Appendix B
The following table lists the diagnostic manifestations of sepsis based on different variables.
Table 1: Clinical diagnostic criteria for sepsis
Suspected or documented infection and some of the following factors:
General variables  Fever (> 38.3 C)
 Hypothermia (core temperature < 36.0 C)
 Heart rate > 90 bpm or more than two SD
above the normal value for age
 Tachypnea
 Altered mental status
 Significant edema or positive fluid
balance (>20 mL/kg over 24 h)
 Hyperglycemia (plasma glucose >140
mg/dL) in the absence of diabetes.
Inflammatory variables  Leukocytosis (WBC count > 12,000)
 Leukopenia (WBC count < 4,000)
 Normal WBC count with greater than
10% immature forms
 Plasma C-reactive protein more than two
SD above the normal value
 Plasma procalcitonin more than two SD
above the normal value
Hemodynamic variables  Arterial hypotension (SBP < 90 mmHg,
MAP < 70 mmHg, or an SBP decrease >
40 mmHg in adults or less than two SD
below normal for age)
Tissue perfusion variables  Hyperlactemia (> 1 mmol/L)
 Decreased capillary refill or mottling
Organ dysfunction variables  Acute oliguria (urine output < 0.5
mL/kg/hr for at least 2 hours despite
adequate fluid resuscitation)
 Creatinine increase > 0.5 mg/dL
(Wagenlehner, 2013, p. 964)

Appendix C: Piperacillin/tazobactam
Medication
name
Dose range Mechanism
of action
Required assessments
(vitals, labs, etc)
Data that
indicates the
med is effective
piperacillin/tazo
bactam
(Zosyn)
Functional class:
Antiinfective,
broad spectrum
Chemical class:
Extended-
spectrum
penicillin, β-
lactamase
inhibitor
4.5 g q6hr
or 3.375 g
q4hr with an
aminoglyco
side or
antipseudo
monal
fluoroquinol
one X 1-2
weeks.
Interferes
with cell-wall
replication of
susceptible
organisms;
tazobactam is
a β-lactamase
inhibitor that
protects
piperacillin
from
enzymatic
degradation.
Intake and output:
- Report hematuria
- Report oliguria because
penicillin in high doses is
nephrotoxic
- Maintain hydration unless
contraindicated
Blood studies:
- WBC RBC, Hct, Hgb,
bleeding time before
treatment and periodically
thereafter
- Monitor serum potassium
levels
Renal studies:
- Urinalysis, protein, blood,
BUN and creatinine
before treatment and
periodically thereafter.
Therapeutic
response to
drug:
- Absence of
fever,
purulent
drainage,
redness, and
inflammation;
culture shows
decreased
organisms.
Adverse and life
threatening effects
Food, drug and med
interactions
Patient teaching
CNS: Seizures
Cardiovascular: Cardiac
toxicity
Gastrointestinal:
Pseudomembranous colitis
and pancreatitis
Genitourinary: Oliguria,
proteinuria, hematuria,
glomerulonephritis and renal
failure
Hematology: Bone marrow
Decreases
piperacillin’s effects:
- Tetracyclines and
aminoglycosides IV
Drug/lab test:
- Increases the
following:
Eosinophilia,
neutropenia,
leukopenia, serum
creatinine, PTT,
AST, ALT,
bilirubin, BUN and
electrolytes.
Teach patient:
- That culture may be obtained after
completed course of medication.
- To wear or carry emergency ID if
allergic to penicillins.
- To notify nurse of diarrhea.
- To report the following symptoms:
o Superinfection: Sore throat,
fever, and fatigue.
o CNS effects: Anxiety,
depression, hallucinations and
seizures.
o Pseudomembranous colitis:
Fever, diarrhea with blood, pus,
and mucous.

depression, agranulocytosis
and hemolytic anemia.
Systemic: Serum sickness,
anaphylaxis, Stevens-Johnson
syndrome
- Decreases the
following: Hct,
Hgb, and
electrolytes.
- False positive for
the following: Urine
glucose, urine
protein and
Coombs’ test.
(Skidmore-Roth, L., 2015, p. 952-954)

Appendix D
The following table provides the characteristics of the different types of dehydration based on its
sodium concentration levels.
Table 8.3: Classifications of Dehydration: Sodium Considerations
Dehydration
Category
Sodium
Concentration
Frequency of
Diagnosis
Type of Fluid
Loss
Fluid Shifts
Hyponatremic < 130 mEq/L 5-10% Hypertonic Intravascular to
Extravascular
Isonatremic 130-150 mEq/L 80% Isotonic None
Hypernatremic > 150 mEq/L 5-10% Hypotonic Extravascular to
Intravascular
(Braun & Anderson, 2007, p. 213)

Appendix E
The following table lists the clinical manifestations of dehydration based on its different forms:
mild, moderate and severe.
Table 1: Clinical Findings of Dehydration
Symptom/Sign Mild Dehydration Moderate
Dehydration
Severe Dehydration
Level of
consciousness
Alert Lethargic Obtunded
Capillary refill * 2 seconds 2-4 seconds > 4 seconds, cool
extremities
Mucous membranes Normal Dry Parched, cracked
Heart rate Slightly increased Increased Very increased
Respiratory
rate/pattern *
Normal Increased Increased and
hyperpnea
Blood pressure Normal Normal, but
orthostasis
Decreased
Pulse Normal Thready Faint or impalpable
Skin turgor * Normal Slow Tenting
Eyes Normal Sunken Very sunken
Urine output Decreased Oliguria Oliguria/anuria
* Best indicators of hydration status
(Huang et al., 2014)

Appendix F
The following table lists the normal laboratory values for an adult as reported by Farinde (2014).
In addition, it states the abnormal findings consistent with dehydration as explained by
Ignatavicius and Vorkman (2015, p. 157).
Lab values Normal findings Abnormal findings
consistent with
dehydration
Blood glucose 65-110 mg/dL > 110 mg/dL
Hemoglobin 13 - 17 g/dL (men)
12 - 15 g/dL (women)
> 17 g/dL (men)
> 15 g/dL (women)
Hematocrit 40% - 52% (men)
36% - 47% (women)
> 52% (men)
> 47% (women)
Albumin 35 – 50 g/L > 50 g/L
Blood urea nitrogen 8 – 21 mg/dL > 21 mg/dL
Creatinine 0.8 – 1.3 mg/dL > 1.3 mg/dL
(Farine, 2014), (Ignatavicius & Vorkman, 2015, p. 157).

Appendix G: Midazolam
Medication name Dose range Mechanism of
action
Required
assessments
(vitals, labs, etc)
Data that
indicates the
med is effective
midazolam
Controlled
substance
(Schedule IV)
Functional class:
Sedative,
hypnotic, anti-
anxiety
Chemical class:
Benzodiazepine,
short-acting
Preoperative
sedation:
Adult: IM
0.07-0.08
mg/kg ½-1
hour before
general
anesthesia
Depresses
subcortical levels
in CNS; may act
on limbic system,
reticular
formation; may
potentiate y-
aminobutyric acid
(GABA) by
binding to specific
benzodiazepine
receptors.
Cardiovascular:
- Monitor blood
pressure and
pulse.
Respiratory:
- Monitor
respirations.
- This drug has a
Black Box
Warning of
respiratory
depression
insufficiency.
Therapeutic
response of
drug:
- Induction of
sedation.
Adverse and life
threatening effects
Food, drug and med interactions Patient
teaching
CNS: Retrograde amnesia
Cardiovascular: Cardiac
arrest
EENT: Loss of vision
Respiratory: Apnea,
bronchospasm,
laryngospasm, and
respiratory depression.
Increases respiratory depression:
- CNS depressants, alcohol, barbiturates,
opiate analgesics, verapamil.
Drug/Herb:
- Increases sedation: Kava and valerian
- Decreases midazolam’s effect: St. John’s
wort.
Drug/Food:
- Increases midazolam’s effect: Grapefruit
juice
Teach patient:
- That
amnesia
occurs and
events may
not be
remembered.
(Skidmore-Roth, L., 2015, p. 795-796)
Appendix H: Tramadol

Medication
name
Dose range Mechanism of
action
Required assessments
(vitals, labs, etc)
Data that
indicates the
med is
effective
tramadol
(Conzip,
Ultram,
Zytram)
Functional
Class:
Analgesic
For mild to
moderate pain:
Adults: PO
25-400 mg/day.
25 mg daily,
titrate by 25 mg
after two days
to 100 mg/day
(25 mg qid)
Then, may
increase by 50-
100 mg q4-6hr.
Must not
exceed 400 mg
daily.
Binds to μ-
opioid
receptors and
inhibits
reuptake of
norepinephrine,
serotonin.
Pain assessment:
- Assess the following
characteristics of pain:
location, type, and
character.
Respiratory assessment:
- Assess the respiration
rate.
- The drug must be
withheld if respiration
rate is less than 12
breaths per minute.
Changes in lab values:
- Increase: Creatinine and
hepatic enzymes
- Decrease: Hemoglobin
Therapeutic
response to
drug:
- A
reduction
in pain.
- An
absence of
adverse
reactions.
Adverse and life
threatening effects
Food, drug and med
interactions
Patient teaching
CNS: Seizures
Systemic: Anaphylaxis,
Stevens-Johnson syndrome,
toxic epidermal necrolysis
CNS depression:
- If taken with
alcohol, hypnotics,
sedatives and
opiates
- Or if taken with
certain herbs (e.g.,
chamomile, hops,
kava, skullcap, and
valerian)
Serotonin syndrome:
- If taken with SSRIs,
SNRIs, serotonin-
receptor agonists
Decreases drug
effects:
- Barbiturates,
Teach patient:
- To rise slowly when changing
positions from lying to sitting or
standing due to potential orthostatic
hypotension.
- To report any abnormal symptoms,
such as CNS changes, allergic
reactions, serotonin syndrome, and
seizures.
- To not taper off the drug versus
discontinuing the drug abruptly.
- To avoid OTC medications, herbs,
supplements, CNS depressants, and
alcohol unless approved by the
prescriber.

phenytoins,
rifampin, rifabutin.
(Roth-Skidmore, L., 2015, p. 1193-1194)
Extra Credit NCLEX Question

1.) Which of the following hospitalized clients would the nurse be most concerned is at risk
for developing an imbalance related to water loss? Select all that apply.
A. A 50-year old undernourished female
B. A 75-year old female of average body weight
C. A 60-year old male of average body weight
D. A 45-year old obese male
The correct answer is: B and D
Rationale:
A. This patient does not pose a risk for dehydration. She is under the age of 65 and
is not obese.
B. After age 65, total body water may reduce to as much as 45-50% compared to the
total body weight. Therefore, an age greater than 65 is at increased risk for
dehydration.
C. This patient is not at risk for dehydration due to lack of risk factors. He is not
above age 65 and is average body weight.
D. The greater the total body weight is, the lesser the proportion of fluid volume in
the body. Therefore, the obese patient has a higher risk of dehydration.
Reference
LeMone, P., Burke, K. (2007). Medical-surgical nursing: Critical thinking in client care. (4th
ed.). Upper Saddle River, NJ: Prentice Hall.

SBAR Paper on Urosepsis and Dehydration

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