Choose the matching protocol signs that fit with each scenario
Suspected/knowledge WBCs 22
of infection in the
RR 28
peritoneal
HR 130
cavity/Peritonitis &
abscess
WBC < 4 with > or
equal to 10% bands
RR > 20 and PCO2
<32
HR > 90
Temp < 36
WBCs > 12
RR > 20 & PCO2 < 32
HR > 90
Confirmed UTI
WBC 12 with 2%
bands
PCO2 < 32
HR > 90
Choose the matching diagnostics that fit each scenario
Elevated CRP
pCO2 <32
WBCs 12 with 2%
Bands
Lactate 2
eGFR 45
Low K+ - Hypokalemia
Elevated CRP
pCO2 <32
WBCs 14
No bands present
eGFR 65
Low K+ Hypokalemia
CRP grossly elevated
Blood glucose 12
PCO2 29
WBCs 22
Bands >12%
Lactate 8
eGFR 25
Platelets 80 (very
low)
CRP grossly
elevated
Blood glucose 12
PCO2 30
WBCs 3.9
Bands 10%
Lactate 4
eGFR 25
Low K+ Hypokalemia
Low Mg+, PO4 hypomagnesia,
hypophosphatemia
Platelets 80 (very
low)
Low K+ Hypokalemia
Low Mg+, PO4 hypomagnesia,
hypophosphatemia
Choose the expected assessment findings that fit each scenario
BP 109/65 mmHg
HR 108 bpm
O 2 Sat 90% on 4L NP
T 38.5 po
RR 20/min
A&O time 1, pain
9/10, Disorientated to
place and time
Decreased a/e
bilateral bases, SOB
Edema noted bilateral
ankles Left > Right,
Peripheral pulses
weak, limbs cool to
touch and pale, cap
refill > 3 seconds
Abd soft, BS present
U/O 25 cc/hr
BP 75/55
HR 130
O 2 Sat 91% on
highflow 50%
oxygen
Temp 39 po
RR 28 and shallow
Disorientated
Decreased a/e
bilateral bases with
coarse breath
sounds bilateral
mid lobe, O2sat
91% via face mask
with 50% oxygen.
Use of accessory
muscles to breath
Tachycardia,
hypotension
BP 110/60 mmHg
HR 96 bpm
O2 Sat 94% on 2L NP
T 37.9 po
RR 24/min
A&O times 3, pain
9/10
Coarse crackles
bilateral bases,
slightly SOB
Slight generalized
peripheral edema,
cap refill < 3 seconds,
peripheral pulses
bounding
Abd firm and tender,
no BS, no flatus
U/O 40 cc/hr
Skin flushed and
warm to touch
BP 80/64 mmHg
HR 115 bpm
O 2 Sat 91% on 5L
NP
T 35.4 po
RR 24/min
A&O time 2, pain
9/10
No a/e bilateral
bases, a/e upper
lobes only, SOB
when trying to
speak
Family notice his
hands and feet are
swollen.
Weak peripheral
pulses, cap refill
sluggish > 3
seconds, limbs cool
despite major fluid
resuscitation
Peripheral mottling
to lower limbs, cap
refill > 3 seconds,
pulses weak
Abd frim and
distended, BS
absent, no flatus
no urine output
Skin cold and
clammy, chills and
rigorous (shaking
with fever)
to touch with
peripheral mottling
from knees to
lower limbs
bilateral
Abd firm and
distended with
rebound
tenderness, no BS,
no flatus
U/O 20 cc/hr
Choose the best course of treatment that fit each scenario
1. Call RT and
switch patient
to O2 via face
mask
2. Elevated HOB
to maximize
oxygenation
3. Monitor O2sat
> Q1H
4. NS bolus 500 cc
immediately
1. Call RT and
physician
2. Continuously
monitor
O2sat & be
ready to
oxygenate
via bag-valve
mask
3. Another
bolus of NS
500 cc and
1. Elevate HOB 30
degrees or >,
Incentive
spirometer and
DB exercises
2. Reorient
patient
3. Administer IV
NS bolus 250 cc
for low
circulating
volume
1. Continue to
monitor
oxygenation
and support
to keep O2 >
92%
2. Administer
IV NS bolus
500cc for low
circulating
volume
5. Call physician
for possible
colloid
(Albumin)
administration
& assessment
for CT
scan/surgery
6. Administer
antibiotics
7. Change IV to
NS with 20mEq
KCL
8. Call ICU
outreach for
possible
inotropic
support if bolus
doesn’t help BP
& U/O or if
oxygenation
does not
improve.
call ICU
outreach for
inotropic
medication
4. Balance
elevation of
HOB to
maximize
oxygenation
but supine
to support
BP.
5. Administer
antibiotics
6. IV would
already have
20mEq KCL
4. Change IV to
NS with 20mEq
KCL
5. Administer
antibiotics
6. Administer
acetaminophen
for fever
7. Assess Q1H for
hypoxia,
hypovolemia,
fever, &
oliguria
3. Assess Q1H
for hypoxia,
hypovolemia,
fever, &
oliguria
4. Change IV to
NS with
20mEq KCL
@150 cc/hr
5. Administer
antibiotics as
ordered