Day 1 – ICU

Patient transferred from E.D. at 1200. Pt’s diagnosis is pneumonia/sepsis and acute respiratory failure. Zosyn IV has been initiated in the ED. Pt’s VS are as follows: BP: 107/61; HR: 105; RR: 13; O₂: 90%; T: 102.0. Patient is intubated with vent settings on A/C: Peep: 5; VTE: 500; I/E: 1.2; and FiO₂: 1.0. The pt is sedated with midazolam 3 mg/hr. The pt is sinus tach on the monitor with a HR in the 120s. S₁S₂ is present. Pulses are weak in all extremities. Skin is hot and dry to the touch. Cap refill is 3 seconds. Crackles are present in the upper lung fields and right lower lobe. Lung sounds are diminished in the left lower lobe. Bowel sounds are present in all four quadrants and the abdomen is soft and non-tender. The pt has a Foley with 50 mL of dark urine draining to gravity. Skin is intact. The pt has an arterial line in his left arm. Site is clean, dry, and intact. Pt has a triple lumen PICC line present on his right upper arm that is patent. The site is clean, dry, and intact.