Page 2559 - Saunders Comprehensive Review For NCLEX-RN

▪ Tachycardia (heart rate above 90 beats per minute)

▪ Tachypnea (respiratory rate above 22 breaths per minute)
▪ Systolic blood pressure (SBP) less than or equal to 100 mm Hg or arterial
hypotension (SBP below 90 mm Hg), MAP below 70 mm Hg, or a decrease in
SBP of more than 40 mm Hg
▪ Altered mental status
▪ Edema or positive fluid balance

▪ Oliguria
▪ Ileus (absent bowel sounds)
▪ Decreased capillary refill or mottling of skin

Laboratory Values

▪ Hyperglycemia (blood glucose greater than 140 mg/dL (8 mmol/L) in client
without diabetes)
▪ Leukocytosis or leukopenia
▪ Normal white blood cell count with more than 10% immature bands
▪ Elevated C-reactive protein
▪ Elevated procalcitonin
▪ Serum creatinine increase
▪ Coagulation abnormalities (INR above 1.5 [1.5] or PTT above 60 seconds [for
more than 60 seconds])
9
3
▪ Thrombocytopenia (platelets below 100,000/mm (100 × 10 /L))
▪ Hyperbilirubinemia (total bilirubin above 4 mg/dL [68 mcmol/L])
▪ Hyperlactatemia (above 1 mmol/L)

Adapted from Lewis et al. (2017), p. 1592.

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