nursing case study septic shock

Septic Shock (Sepsis) Case Study (45 min)

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What initial nursing assessments need to be performed for Mr. McMillan?

• Full set vital signs (T, P, RR, BP, SpO 2 )
• OLDCARTS or PQRST assessment of symptoms (urinary burning)
• LOC/orientation assessment
• Heart and lung sounds

Upon further assessment, Mr. McMillan is weak, his face is flushed, his skin is warm and dry. He is oriented to person and place, but states the year is 1952. His vital signs were as follows:

BP 99/60 mmHg Ht 170.2 cm

HR 92 bpm and regular Wt 60 kg 

RR 28 bpm SpO 2 93% on Room Air

Temp 38.9°C

What diagnostic tests should be ordered for Mr. McMillan?

•  Blood Tests – CBC, BMP, ABG, Lactic Acid, Blood Cultures x 2
• Urine Tests – Urinalysis, Urine Culture
• X-rays – Chest, Kidneys/Ureters/Bladder

What nursing actions would you take at this time for Mr. McMillan? Why?

•  Elevate the HOB to improve breathing and oxygenation
• Apply cardiac monitor
• Notify provider of elevated temp and low SpO 2  
• Apply cool washcloth to forehead and/or behind neck for comfort
• Possibly get ice packs to axillae and groin and remove any blankets to help bring the patient’s temperature closer to normal.

The ED provider orders the following:

• Bloodwork – CBC, BMP, ABG, Lactic Acid, Blood Cultures x 2
• Diagnostics – CXR (chest x-ray), KUB (x-ray of kidneys, ureters, and bladder)
• Nasal Cannula to keep SpO 2 > 92%
• Meds – 1L Normal Saline bolus IV x 1, now.  1,500 mg Vancomycin IVPB x 1 dose, now

Which order should you implement first? Why?

• Blood and urine cultures must be drawn before any antibiotics are administered.
• Blood work – urine tests – fluids – antibiotics
• IF the patient’s SpO 2 is below 92%, apply oxygen via nasal cannula – at this time, there is no indication of that, yet.

All blood and urine tests are completed and you initiate the fluid bolus for Mr. McMillan. You are still waiting for the Vancomycin to arrive from the pharmacy. You notice he is more drowsy. He is now only oriented to self and feels warmer. You take another set of vital signs to find the following:

BP 86/50 mmHg MAP 62 mmHg

HR 108 bpm Temp 39.3°C

RR 36 bpm SpO 2 88% on Room Air

Mr. McMillan’s lab results have also resulted, the following abnormal values were reported:

WBC 22,000 / mcL Lactic Acid 3.6 mmol/L

pH 7.22 pCO 2 30 mmHg

HCO 3 16 mEq/L pO 2 64 mmHg

Urine Cloudy with sediment

What action(s) should you take at this time? Why?

•  #1 – apply oxygen via nasal cannula – ensure HOB elevated for easy breathing
• Notify provider of decreasing blood pressure and elevated WBC, lactic acid ANSWER

What orders do you anticipate for Mr. McMillan? (procedures, meds, transfer, etc?)

• Mr. McMillan may need another liter of IV fluids. The guidelines are for patients to receive 30 mL/kg of body weight in the first 6 hours. That means he would need to receive at least 1,800 mL of IV fluid bonuses.
• Mr. McMillan may need vasopressors to improve his blood pressure – in which case he will also need a central line for administration of those medications as well as an arterial line to monitor his MAP.
• Mr. McMillan will need to be transferred to the ICU for close monitoring and management of his drips

Mr. McMillan responds well to the first liter of fluids, and antibiotics are initiated within an hour of arrival. The ED physicians place an arterial line and central line to initiate vasopressors. They order a Norepinephrine infusion to be titrated to keep MAP > 65 mmHg. The Critical Care team asks you to prepare the patient for transfer to the ICU.

Art. Line BP 82/48 mmHg MAP 58 mmHg

HR 122 bpm CVP 4 mmHg

RR 32 bpm SVR 640 dynes/sec/m -5 SpO 2 90% on Room Air

What, physiologically, is going on with Mr. McMillan?

• Mr. McMillan has an infection, likely urinary, and it has created a systemic inflammatory response. That inflammatory response is causing massive peripheral vasodilation so his vital organs are not receiving adequate blood flow
• He is showing signs of decreased perfusion to his brain (↓ LOC) and decreased cardiac output (↓ BP).  
• His skin is warm and flushed and his temperature is elevated because of the vasodilation in the non-vital organs.

What does it mean to titrate an infusion to keep MAP >65?

• Titration means achieving the desired result with the least amount of drug possible. Therefore we would adjust the infusion up or down to maintain the MAP above, but not too far above, 65 mmHg

After 2 days in the ICU, a norepinephrine infusion and a total of two liters of normal saline, Mr. McMillan’s blood pressure is stable, his MAP is 67 mmHg. He is becoming more alert and is now oriented to person, place, and time.  His blood and urine cultures were positive for bacterial growth. He has received multiple doses of Vancomycin as well as antibiotics targeted to his specific bacterial infection. He is being weaned off of the vasopressors, and the providers hope he can transfer out of the ICU tomorrow.

What explanation or education topics would you want to provide to the patient and his caregiver before discharge?

• Sepsis and septic shock are a result of a severe infection that has gotten into the bloodstream and affected the patient’s ability to pump blood to the body. This is what makes their blood pressure drop so low. We treat this condition by getting the infection under control and supporting the patient’s blood pressure.
• Signs and symptoms of infection – in elderly people, one of the first signs of infection is altered mental status. If the patient seems ‘off’ or ‘not themselves’, it is worth notifying a healthcare provider to prevent a worse situation. 
• The patient will need to ensure he is drinking plenty of fluids and practicing good hygiene to prevent urinary tract infections. He may also consider cranberry juice.
• If receiving a PO course of antibiotics – be sure to take the full course and notify HCP of any adverse reactions.

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This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

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A 26-year-old female arrives with a companion to an urgent care at 0845 by personal vehicle for treatment of suspected foot infection. The patient’s companion (a female roommate) reports to the triage nurse that the patient cut her foot while wading in the ocean over the weekend. They did not initially notice the cut but discovered it while removing tar from the bottom of the right foot. Approximately 24 hours later, her foot became too painful for ambulation, and a “thick, yellowish” discharge began to drain from the cut. Vitals upon arrival at urgent care showed a temperature of 101.5F, heart rate of 130, respiratory rate of 24, and blood pressure of 86/40. Her pain was 9/10 in her right foot and described as throbbing. During a HTT assessment by the PA, the patient is reported to be arousable to voice, oriented to person and place only, and complaining of nausea. The patient reports she took Tylenol that morning to relieve pain and fever. Her skin is pale, diaphoretic, and hot.

The urgent care calls 911, and medics are dispatched to the center for transfer to the local hospital to treat the patient for suspected sepsis. Upon arrival, medics find the patient is still tachycardic, and that her blood pressure has dropped to 80/40. Her respiratory rate has increased to 30. During transport, medics insert a 20 gauge peripheral IVs in the patient’s left antecubital. They infuse a fluid bolus of 500 mL of normal saline to manage her patient’s hypotension, and administer oxygen by simple mask at 4L/min. During the primary assessment, the patient’s right foot reveals a two-inch laceration with no active bleeding that is erythematous, edematous (non-pitting), and radiating heat. Edema is covering the entire bottom of the right foot and extends to the patient’s ankle.

The patient arrives to the emergency room within 15 minutes and is admitted for treatment at 1000. On the unit, Code Sepsis is called, and the agency’s sepsis protocol based on the Surviving Sepsis campaign is implemented. The patient’s vitals are now a temperature of 102F, heart rate of 140, respiratory rate of 34, and blood pressure of 96/42. Lactate levels are immediately measured. A second 20 gauge peripheral IV is inserted into the right antecubital, blood cultures are drawn, and a swab sample is taken of the cut and submitted to the laboratory for a culture and sensitivity test. Broad spectrum antibiotic ceftriaxone (Rocephin) is administered, and patient is given Ibuprofen to manage her fever. The patient is diagnosed with septic shock, and because she is still hypotensive, 30mL/kg of normal saline is infused. The patient’s lactate levels come back as 2.4 mmol/L. Norepinephrine (Levophed) is also hung, and the patient is further monitored. With careful titration and vital monitoring, the use of vasopressors restores the patient’s blood pressure to 101/52. Although fluid resuscitation helps to bring the patient’s heart rate down to 104, Nicardipine (Cardene) was ordered in anticipation of further needs to manage tachycardia. The patient is transferred to the ICU at 1300 for further monitoring and management of her hemodynamic status.

In the ICU, the patient’s vitals stabilize. Her tachypneic state reduces, and respiratory rate is now 18. She no longer requires oxygen supplementation. Her pain is being managed with IV morphine and she rates the pain in her as 3/10. Her IV pump is running 125 mL an hour of normal saline along with piggybacked ceftriaxone (Rocephin), and labs return a lactate level of 1.5 mmol/L. The patient’s roommate arrives. She is tearful and explains to the ICU nurse that she wanted to tell the patient’s parents what happened, but the patient refused. The ICU nurse calls for the case manager and a social service consult to inquire further. The patient’s roommate explains to the interdisciplinary team that the patient does not have insurance because she is 26 and has been removed from her parents’ medical plan. The parents are also currently engaged in a divorce, do not speak to each other, and use their daughter to communicate. The patient is aware of their financial situation and her lack of medical coverage and does not want to worry her parents in spite of her critical medical state.

• What are the priority nursing interventions for this patient in the ICU setting?
• What signs and symptoms in this patient would indicate the need for mechanical ventilation?
• What is the nurse’s role in addressing the patient’s financial concerns?

References:

Gordon, A.C., Mason, A.J., Thirunavukkarasu, N., et al. (2016). Effect of early vasopressin vs norepinephrine on kidney failure in patient with septic shock: The VANISH randomized clinical trial. JAMA, 316 (5), 509–518. doi:10.1001/jama.2016.10485

Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth’s textbook of medical-surgical nursing. Philadelphia: Lippincott Williams & Wilkins. PulmCCM. (2019, January 14). From the Surviving Sepsis Guidelines: Criteria for diagnosis of  sepsis. Retrieved from https://pulmccm.org/review-articles/surviving-sepsis-guidelines-criteria-diagnosis-sepsis/

Schmidt, G.A., & Mandel, J. (2019, March). Evaluation and management of suspected sepsis  and septic shock in adults. Retrieved from https://www.uptodate.com/contents/evaluation-and-management-of-suspected-sepsis-and-septic-shock-in-adults?search=sepsis treatmentadult&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H465649907

Society of Critical Care Medicine. (2019). Hour-1 bundle: Initial resuscitation for sepsis and  septic shock. Retrieved from http://www.survivingsepsis.org/SiteCollectionDocuments/Surviving-Sepsis-Campaign-Hour-1-Bundle.pdf

Zhang, M., Zheng, Z., & Ma, Y. (2014). Albumin versus other fluids for fluid resuscitation in patients with sepsis: A meta-analysis. PloS one , 9 (12), e114666.

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Septic shock (nursing).

Sidharth Mahapatra ; Alan C. Heffner ; Janet M. Atarthi-Dugan .

Affiliations

Last Update: June 12, 2023 .

• Learning Outcome
• Recall the causes of septic shock
• Describe the presentation of septic shock
• Summarize the treatment of septic shock
• List the nursing management role in septic shock
• Introduction

Sepsis syndromes span a clinical continuum with variable prognoses. Septic shock, the most severe complication of sepsis, carries a high mortality. In response to an inciting agent, pro-inflammatory and anti-inflammatory arms of the immune system are activated in concert with the activation of monocytes, macrophages, and neutrophils that interact with the endothelium through pathogen recognition receptors to elaborate cytokines, proteases, kinins, reactive oxygen species, and nitric oxide. [1] As the primary site of this response, the endothelium not only suffers microvascular injury but also activates the coagulation and complement cascades which further exacerbate vascular injury, leading to capillary leak. This cascade of events is responsible for the clinical signs and symptoms of sepsis and progression from sepsis to septic shock. The ability to balance pro-inflammatory responses to eradicate the invading microorganism with anti-inflammatory signals set to control the overall inflammatory cascade ultimately determines the degree of morbidity and/or mortality suffered by the patient. Judicious and early antimicrobial administration, sepsis care bundle use, and early goal-directed therapies have significantly and positively impacted sepsis-related mortality. However, early identification remains the best therapeutic tool for sepsis treatment and management.

• Nursing Diagnosis
• Ineffective healing
• Imbalance in body fluids
• Inadequate oxygenation and breathing
• Impaired body defense mechanisms
• Altered mental status

The 2009 European Prevalence of Infection in Intensive Care (EPIC II study) determined that gram-negative bacterial infections far exceed other etiologies as the most common cause of sepsis syndromes with a frequency of 62%, followed by gram-positive infections at 47%. An increase in the prevalence of the latter may be attributable to the performance of more invasive procedures and increased incidence of nosocomial infections. [2] Predominant micro-organisms isolated in patients include Staphylococcus aureus (20%), Pseudomonas (20%), and Escherichia coli (16%). [3]  Predominant sites of infection include respiratory (42%), bloodstream (21%), and genitourinary (10%). [2] These data need to be assessed in the context of knowing that over a third of patients never grow positive cultures. [4]

The influence of bacterial strain and site of infection on mortality was illustrated in a large meta-analysis. [5] In this study, gram-negative infections were overall associated with higher mortality. However, gram-positive bacteremia with Acinetobacter or pneumonia with Staphylococcus carried a 40% mortality with Pseudomonal pneumonia carrying the highest mortality at 70%.

Sepsis syndromes caused by multidrug-resistant bacterial strains (methicillin-resistant Staphylococcus (MRSA), vancomycin-resistant enterococci (VRE)) are on the rise with a current incidence of up to 25%; viruses and parasites cause far fewer cases and are identified in 2% to 4% of cases. [6]

• Risk Factors

Annually, the rate of this debilitating condition is rising by almost 9%. [7] The incidence of sepsis and severe sepsis have risen over the past decade from approximately 600,000 to over 1,000,000 hospitalizations per year from 2000 through 2008. [8] Accompanying this trend has been a rise in healthcare expenditure, making sepsis the most expensive healthcare condition in 2009, accounting for 5% of total United States hospital costs. [9] The case fatality for patients with sepsis has been declining due to advances in sepsis management provided by the Surviving Sepsis Campaign. The United States Nationwide Inpatient Sample (NIS) from 2009 through 2012 showed a mortality rate declined from 16.5 to 13.8%. [10]  However, severe sepsis continues to rank amongst the most common causes of death in hospitalized patients. [11] Moreover, up to 25% of patients with severe sepsis and 50% of patients with septic shock will suffer mortality. [2] However, overall mortality from sepsis syndromes can vary from 30% to 50% [12]  depending on demographic factors such as age, race, sex, co-morbid conditions, and the presence of organ dysfunction. [13] For example, in-patient mortality was predicted most by number and degree of organ injury with the strongest predictors being respiratory, cardiovascular, hepatic, and neurologic failure. [10]

Early Signs and Symptoms

Sepsis is defined as systemic inflammatory response syndrome plus an infectious source. Therefore, earlier on in the presentation of sepsis, patients present with the following vital sign changes:

• Fever, temperature higher than 38 C, or hypothermia, temperature lower than 36 C
• Tachycardia with a heart rate higher than 90 beats per minute in adult patients or less than two standard deviations for age in pediatric patients
• Tachypnea with respiratory rate greater than 20 breaths per minute in adult patients or more than two standard deviations for age in pediatric patients

Signs and Symptoms of Severe Sepsis Severe sepsis is defined as sepsis and end-organ dysfunction. At this stage, signs, and symptoms may include: 

• Oliguria or anuria

Patients progressing to septic shock will experience signs and symptoms of severe sepsis with hypotension. Of note, at an early "compensated" stage of shock, blood pressure may be maintained, and other signs of distributive shock might be present, for example, warm extremities, flash capillary refill (less than one second), and bounding pulses, also known as warm shock. This stage of shock, if managed aggressively with fluid resuscitation and vasoactive support, can be reversed. With the progression of septic shock into the uncompensated stage, hypotension ensues, and patients may present with cool extremities, delayed capillary refill (more than three seconds), and thready pulses, also known as cold shock. After that, with continued tissue hypoperfusion, shock may be irreversible, progressive rapidly into multiorgan dysfunction syndrome and death.

Laboratory Findings

Findings in sepsis, severe sepsis, and septic shock are as follows  [14] : 

• Hyperglycemia (glucose more than 120 mg/dL)
• Leukocytosis (WBC more than 12,000/mm3) or leukopenia (WBC less than 4000/mm3)
• Bandemia (more than 10%)
• C-reactive protein or procalcitonin more than 2 SD above normal
• Mixed venous saturation more than 70%
• PaO2: FiO2 less than 300
• Pre-renal azotemia
• Coagulopathy, INR more than 1.5 or PTT more than 60 sec
• Thrombocytopenia (platelets less than 100,000/mL)
• Hyperbilirubinemia (total bilirubin more than 4 mg/dL)
• Lactic acidosis (more than 2 mmol/L)

Patients should be placed on continuous cardiopulmonary monitoring to allow close observation of vital signs. A thorough assessment of end-organ function and peripheral perfusion should be undertaken to determine where along the pathophysiologic continuum of sepsis they may fall. This should include a Glasgow Coma Scale (GCS) or mental status assessment, urine output measurement, or lactate/mixed venous saturation determination (with central lines). Regardless of where along the continuum patients are, all patients should have drawn a complete blood count with differential (CBC-d), source cultures (blood, urine, tracheal (if intubated), wound), and a urinalysis. Depending on the severity of presentation and age of the patient a lumbar puncture may be indicated, for example, patients with signs of encephalitis or meningitis or febrile pediatric patients under six weeks of age. The addition of C-reactive protein or procalcitonin, both acute-phase proteins, may be helpful in distinguishing viral from bacterial sepsis, with the latter showing steeper elevations in these proteins. A complete chemistry panel with liver function test, disseminated intravascular coagulation (DIC) panel, and an arterial blood gas are additional labs that may provide important information on the severity of sepsis syndrome in a patient.

• Medical Management

Below guidelines are derived from the Surviving Sepsis Campaign Guidelines  [15] [16]

Source Control

• Broad-spectrum antibiotics within one hour of diagnosis for all patients. Initial empiric anti-infective therapy should have activity against all likely pathogens and adequate penetration of source tissue.  
• Removal of infected/necrotic tissue, if it is the source of septic shock, i.e. patients with cellulitis, abscess, infected devices, purulent wounds.

Management of Shock [17]

• Measures most effective if achieved within the first six hours of diagnosis
• Restore central venous pressure (CVP) to 8 mmHg to 12 mmHg
• Restore mean arterial pressure (MAP) greater than 65 mmHg
• Restore superior vena cava saturation to 70% or mixed venous saturation to 65%
• Fluid resuscitation with crystalloid (NS or albumin) and colloid (blood products) up to 80 ml/kg
• Mechanical ventilation to reduce metabolic demand
• First line vasoactive agents (epinephrine in cold shock versus norepinephrine in warm shock) when fluid-refractoryNote: dopamine as a first line agent has fallen out of favor given its inhibitory effect on the HPA axis, namely prolactin and growth hormone, which can confer immunologic dysfunction [18]

Enhancing Host Response

• Corticosteroids indicated in vasoactive-refractory shock and or in patients with low (unstimulated) basal cortisol levels less than 150 ug/L) [19] [20]
• Addition of vasopressin indicated in vasoactive-refractory shock

While central lines are not required for the resuscitation of patients with septic shock, they provide an accurate means of monitoring CVP and mixed venous saturations. Remember that CVP and MVO2 are most accurate from a central line that lies within the right atrium; lower extremity central lines do not provide the most accurate data for monitoring these indices of resuscitation. Regarding the need for central venous access for administration of vasoactive agents, a recent study showed that both dopamine, norepinephrine, and phenylephrine at high doses could be safely administered via peripheral venous access. [21]  

Of note, early goal-directed therapy (EGDT) has not been shown to confer a survival benefit in more recent studies. [22] All studies comparing EGDT to standard practice have shown an increase in the administration of crystalloid and packed red blood cells in the first six hours and the placement of central lines. Furthermore, survival was influenced most by the maintenance of blood pressure independent of the type of fluid or vasoactive used and not CVP or MVO2. [23] That said, the Surviving Sepsis Campaign guidelines continue to support EGDT as the standard of practice for the management of severe sepsis and septic shock.

The placement of an arterial line becomes important in the management of vasoactive-refractory shock for close monitoring of blood pressure and tissue oxygenation status via regular blood gasses with key attention to lactate levels and pO2.

• Nursing Management
• Monitor vital signs
• Assess neurovitals
• Obtain cultures (blood, urine, sputum)
• Administer antibiotics
• Check labs for electrolytes, renal and liver function
• Ensure patient has DVT and pressure sore prophylaxis
• Consult with dietitian regarding feeding
• Assess oxygenation and ventilation
• Provide oxygen if saturations lower than 92%
• Optimize fluid status
• Measure Ins and outs
• Weigh the patient
• Assess lung sounds for rales, crackles
• Encourage hand washing
• Limit patient visitors
• Educate the family about septic shock
• Prevent aspiration by elevating the head of the bed
• Check labs for culture results and antibiotic sensitivity
• Check chest x-ray report for pneumonia or ARDs
• When To Seek Help
• Hypotension
• Unresponsive
• Outcome Identification

Septic shock is a serious illness and despite all the advances in medicine, it still carries high mortality which can exceed 40%. Mortality does depend on many factors including the type of organism, antibiotic sensitivity, number of organs affected, and patient age. The more factors that match SIRS, the higher the mortality. Data suggest that tachypnea and altered mental status are excellent predictors of poor outcomes. Finally, prolonged use of inotropes to maintain blood pressure is also associated with adverse outcomes. Even those who survive are left with significant functional and cognitive deficits.

• Coordination of Care

The management of septic shock is best done with an interprofessional team that includes ICU nurses. The key is early diagnosis and resuscitation to maintain end-organ perfusion. The type of fluid for resuscitation has little bearing on outcomes but the key is to maintain adequate perfusion pressure. Patients with sepsis are prone to many complications which have high mortality. Thus, close monitoring and prevention of these complications are vital. Primary disorders like diabetes, renal or liver failure must be treated. Drugs that affect the immune system should be discontinued. The dietitian should be consulted as there is good evidence that early enteral nutrition is beneficial. The nurse should ensure DVT and pressure sore prophylaxis. The nurse should also monitor all catheters for infection and remove those that are not needed. The pharmacists should follow culture results and ensure that the patient is on organism-sensitive antibiotics. Clinicians should maintain aseptic techniques during procedures and hand washing should be practiced. The entire team should communicate with each other to ensure that the patient is receiving optimal care.

The outcomes of septic shock depend on patient age, associated comorbidities, renal function, need for dialysis, requiring mechanical ventilation and response to treatment.

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Disclosure: Sidharth Mahapatra declares no relevant financial relationships with ineligible companies.

Disclosure: Alan Heffner declares no relevant financial relationships with ineligible companies.

Disclosure: Janet Atarthi-Dugan declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Mahapatra S, Heffner AC, Atarthi-Dugan JM. Septic Shock (Nursing) [Updated 2023 Jun 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Septic Shock. [StatPearls. 2024] Septic Shock. Mahapatra S, Heffner AC. StatPearls. 2024 Jan
• Sepsis Care Pathway 2019. [Qatar Med J. 2019] Sepsis Care Pathway 2019. Labib A. Qatar Med J. 2019; 2019(2):4. Epub 2019 Nov 7.
• Review Interplay of complement and cytokines in the pathogenesis of septic shock. [Immunopharmacology. 1992] Review Interplay of complement and cytokines in the pathogenesis of septic shock. de Boer JP, Wolbink GJ, Thijs LG, Baars JW, Wagstaff J, Hack CE. Immunopharmacology. 1992 Sep-Oct; 24(2):135-48.
• Review [[Antithrombin III concentrates in the treatmetn of sepsis and septic shock: indictions, limits and future prospects] ]. [Minerva Anestesiol. 2000] Review [[Antithrombin III concentrates in the treatmetn of sepsis and septic shock: indictions, limits and future prospects] ]. Baudo F, de Cataldo F. Minerva Anestesiol. 2000 Nov; 66(11 Suppl 1):3-23.
• Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. [Crit Care Med. 2013] Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, et al. Crit Care Med. 2013 Feb; 41(2):580-637.

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Case Study: A Systematic Approach to Early Recognition and Treatment of Sepsis

Submitted by Madeleine Augier RN BSN

Tags: assessment Case Study emergency department guidelines mortality prevention risk factors sepsis standard of care treatment

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Sepsis is a serious medical condition that affects 30 million people annually, with a mortality rate of approximately 16 percent worldwide (Reinhart, 2017). The severity of this disease process is not well known to the public or health care workers. Often, health care providers find sepsis difficult to diagnose with certainty. Deaths related to sepsis can be prevented with accurate assessments and timely treatment. Sepsis must be considered an immediate life-threatening condition and needs to be treated as a true emergency.

Relevance and Significance

Sepsis is defined as “the life-threatening organ dysfunction resulting from a dysregulated host response to infection” (Kleinpell, Schorr, & Balk, 2016, p. 459). Jones (2017) study of managing sepsis affirms that the presence of sepsis requires a suspected source of infection plus two or more of the following: hyperthermia (>38.1 degrees Celsius) or hypothermia (<36 degrees Celsius), tachycardia (>91 beats per minute), leukocytosis or leukopenia, altered mental status, tachypnea (>21 breaths per minute), or no urine output for 12 hours. If the infection persists, acute organ dysfunction or failure occurs from widespread inflammation, eventually leading to septic shock (Palleschi, Sirianni, O’Connor, Dunn, & Hasenau, 2013).  Palleschi et al.  (2013) states that during septic shock, “the cardiovascular system fails, resulting in hypotension, depriving vitals organs of an adequate supply of oxygenated blood” (p. 23). Ultimately the body can go into multiple organ dysfunction syndrome (MODS), leading to death if there is inaccurate assessment and inadequate treatment.

The purpose of this case study is to make the nurse practitioner aware of the severity sepsis, and how to accurately diagnose and treat using evidence-based data. Sepsis can affect everyone, despite his or her age or comorbidity.  Center for Medicare and Medicaid Services (CMS) has diagnosed this problem as a priority and uses sepsis management in determining payment to providers (Tedesco, Whiteman, Heuston, Swanson-Biearman, & Stephens, 2017). This medical diagnosis is unpredictable and presents a challenge to nurse practitioners worldwide. Early recognition and treatment of sepsis by the nurse practitioner is critical to decrease morbidity and mortality.

After completing this case study, the reader should be able to:

• Identify the risk factors of sepsis
• Identify the signs and symptoms of sepsis
• Identify the treatment course of sepsis

Case Presentation

A 65-year-old Asian female presented to the emergency department accompanied by her husband with a chief complaint of altered mental status. Upon assessment, the patient was lethargic, and alert and oriented to person only. The patient’s heart rate was 136, blood pressure 104/50, oral temperature 99 degrees Fahrenheit, oxygen saturation 97% on 4 liters nasal cannula, and respirations 26 per minute. The patient’s blood glucose was obtained with a result 454.

Further orders, such as labs and imaging were made by the provider to rule out potential diagnoses. A rectal temperature was obtained revealing a fever of 103.7 degrees Fahrenheit. The patient remained restless on the stretcher. After one hour in the emergency department, her heart rate spiked to 203 beats per minute, respirations became more rapid and shallow, and she became more lethargic. The patient’s altered mental status, increasing heart rate and respirations caused the providers to act rapidly.

Medical History

The patient’s husband reports that she is a type one diabetic, he denies any other medical conditions. In addition, the patient’s husband states that she has not been exposed to any sick individuals in the past few weeks. The husband reports a family history of diabetes, other wise no significant familial history. No history of smoking, drinking, or illicit drug use was to be noted.

Physical Assessment Findings

The patient appeared lethargic and confused with a Glasgow Coma Scale of 12. She appeared tachypnic, with shallow respirations, and a rate of 28 breaths per minute. Upon auscultation, breath sounds were coarse. Her abdomen was soft and non-tender, no nausea or vomiting noted. The patient appeared diaphoretic, and her legs were mottled.

Laboratory and Diagnostic Testing and Results

During the initial assessment, a complete blood count (CBC), basic metabolic panel (BMP), and lactic acid level were ordered for blood work. A STAT electrocardiogram (EKG), urinalysis, and a chest X-ray were ordered to differentiate possible diagnoses. The CBC revealed leukocytosis with a white blood cell count of 23,000 and an increased lactic acid level of 4.3. The anion gap and potassium level remained within a normal limit, ruling out the possibility of diabetic ketoacidosis (DKA). The patient’s EKG showed supraventricular tachycardia (SVT). The chest X-ray revealed infiltrates to the right lung. The urinalysis was free from leukocytes or nitrites. Blood cultures were ordered to confirm their hypothesized diagnosis, septicemia.

Pharmacology

The provider initiated intravenous (IV) fluid treatment with Lactated Ringers at a bolus of 30 mL/kg. Because the patient’s heart rate was elevated, 6 mg of adenosine was ordered to combat the SVT. Additionally, broad-spectrum IV antibiotics were initiated. One gram of vancomycin and 3.375 grams of piperacillin-tazobactam were the preferred antibiotics of choice.

Final Diagnosis

Upon arrival, the providers were ruling out DKA and sepsis, given the patient’s history.

The patient’s elevated white blood cell counts, temperature, lactic acid level, heart/respiratory rate, and altered mental status were all clinical indicators of sepsis. The chest X-ray revealed a right lung infiltrate, persuading the providers to diagnose the patient with sepsis secondary to pneumonia.

Patient Management

After sepsis was ruled as the patient’s diagnosis, rapid antibiotic administration and IV fluid treatment became priority after the patient’s heart rate was controlled. A cooling blanket and a temperature sensing urinary catheter was placed to continuously monitor and control the patient’s fever. Later, the patient was transferred to a critical care unit for further treatment. Shortly after being transferred, the patient went into respiratory failure and was placed on a ventilator. After two days in the ICU, the patient remained in septic shock, and died from multisystem organ failure.

When the patient initially presented to the emergency department, accurate and rapid diagnosis of sepsis was critical in order to stabilize the patient and prevent mortality. A challenge was presented to the provider regarding a rapid diagnosis due to the patient’s history and her presenting signs and symptoms. Increased awareness and interprofessional education regarding sepsis and its’ treatment is vital to decrease mortality. Health care providers need to be competent in recognizing and accurately treating sepsis in a rapid manner.

Research shows that outcomes in sepsis are improved with timely recognition and early resuscitation (Javed et al., 2017). It is important for the provider to identify certain risk factors and symptoms to easily diagnose sepsis. A research study by Henriksen et al. (2015) proved that age, and comorbidities including psychotic disorders, immunosuppression, diabetes, and alcohol abuse served as top risk factors for sepsis.

Once the diagnosis of sepsis is determined, rapid treatment must be initiated. The golden standard of treatment consists of a bundle of care that includes blood cultures, broad-spectrum antibiotic agents, and lactate measurement completed within 3 hours as described by Henriksen et al. (2015). A study by Seymour et al. (2017) showed that the more rapid administration of the bundle of care is correlated with a decreased mortality rate. In addition, The Survival of Sepsis Campaign formed a guideline to sepsis treatment; Rhodes et al. (2016) suggests giving a 30 mL/kg of IV crystalloid fluid for hypoperfusion. If hypotension persists (mean arterial pressure <65), vasopressors, preferably norepinephrine, should be initiated (Rhodes et al., 2016). Prompt recognition of sepsis and implementation of the bundle of care can help reduce avoidable deaths.

To increase awareness, interprofessional education regarding sepsis and its’ common signs and symptoms needs to be established. Evidence-based protocols should be utilized in hospital care settings that provide nurse practitioners with a guideline to follow to ensure rapid and accurate treatment is given. Increased awareness and education helps providers and other healthcare workers to properly identify and accurately treat sepsis.

The public and health care providers must become more aware and educated on the severity of sepsis. It is crucial to be able to recognize signs and symptoms of sepsis to prevent further complications such as septic shock and multi-organ failure. Increased awareness, interprofessional education, accurate assessment, and rapid treatment can help reduce incidence and mortality. Sepsis management must focus upon early goal-directed therapy (antibiotic administration, fluid resuscitation, blood cultures, lactate level) and individualized management pertaining to the patient’s history and assessment (Head & Coopersmith, 2016). Misdiagnosis and delay in emergency treatment can result in missed opportunities to save lives.

• Head, L. W., & Coopersmith, C. M. (2016). Evolution of sepsis management:from early goal-directed therapy personalized care. Advances in Surgery, 50 (1), 221-234. doi:10.1016/j.yasu.2016.04.002
• Henriksen, D. P., Pottegard, A., Laursen, C. B., Jensen, T. G., Hallas, J., Pedersen, C., & Lassen, A. T. (2015). Risk factors for hospitalization due to community-acquired sepsis-a population-based case-control study. PLOS ONE, 10 (4), 1-12. doi:10.1371/journal.pone.0124838
• Javed, A., Guirgis, F. W., Sterling, S. A., Puskarich, M. A., Bowman, J., Robinson, T., & Jones, A. E. (2017). Clinical predictors of early death from sepsis. Journal of Critical Care, 42 , 30-34. doi:10.1016/j.jcrc.2017.06.024
• Jones, J. (2017). Managing sepsis effectively with national early warning scores and screening tools. British Journal of Community Nursing, 22 (6), 278-281. doi:10.12968/bjcn.2017.22.6.278
• Kleinpell, R. M., Schorr, C. A., & Balk, R. A. (2016). The new sepsis definitions: Implications for critical care. American Journal of Critical Care, 25 (5), 457-464. doi:10.4037/ajcc2016574
• Palleschi, M. T., Sirianni, S., O'Connor, N., Dunn, D., & Hasenau, S. M. (2013). An interprofessioal process to improve early identification and treatment for sepsis. Journal for Healthcare quality, 36 (4), 23-31. doi:10.1111/jhq.12006
• Reinhart, K., Daniels, R., Kissoon, N., Machado, F. R., Schachter, R. D., & Finfer, S. (2017). Recognizing sepsis as a global health priority-A WHO resolution. The New England Journal of Medicine, 377 (5), 414-417. doi:10.1056/NEJMp1707170
• Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Anotnelli, M., Ferrer, R.,...Beale, R. (2017). Surviving sepsis campaign: International guidelines for management of sepsis and septic shock: 2016. Intensive Care Medicine, 43 (3), 304-377. doi:10.1007/s00134-017-4683-6
• Seymour, C. W., Gesten, F., Prescott, H. C., Friedrich, M. E., Iwashyna, T. J., Phillips, G. S.,...Levy, M. M. (2017). Time to treatment and mortality during mandated emergency care for sepsis. The New England Journal of Medicine, 376 (23), 2235-2244. doi:10.1056/NEJMoal1703058
• Tedesco, E. R., Whiteman, K., Heuston, M., Swanson-Biearman, B., & Stephens, K. (2017). Interprofessional collaboration to improve sepsis care and survival within a tertiary care emergency department. Journal of Emergency Nursing, 43 (6), 532-538. doi:10.1016/j.jen.2017.04.014

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Introduction

Suggested Answer Guidelines

In this unfolding case study, you will assume the role of a nurse in the acute care setting, beginning in the emergency department and ending in the critical care unit. You will use a holistic approach to provide safe care by making correct clinical judgments for a client with suspected sepsis. You will need to apply essential knowledge to notice and interpret the most critical assessment findings and lab values to properly establish care priorities and recognize the potential for developing complications

Preparation for Care Activity

Recognizing Clinical Relationships Review the medical history and home medications of this client. For each home medication, identify the pharm. classification and expected outcome for this client, its most common side effect (SE). Medical History Home Medications Pharm. Classification Expected Outcome Common SE  Parkinson&#039;s Disease  COPD  CHF  HTN  Depression  Stage IV decubitus ulcer  Furosemide 40 mg PO BID  Prednisone 5 mg PO every other day  Potassium 20 mEq Po daily  Carbidopa/Levodopa  Albuterol inhaler  Metoprolol  Silver sulfadiazine topical ointment  Diuretic, loop  Corticosteroid  Mineral &amp; electrolyte replacements/ supplements  dopamine agonists (antiparkinson)  adrenergic  beta blockers  sulfonamides  Inhibit sodium reabsorption and increased excretion of water and Na, K, Cl, Mag, and Ca.  Decreased inflammation  Replace potassium  Relief of tremors and rigidity  Bronchodilation  Decreased rate of cardiovascular mortality and hospitalization in patients with heart failure  Effective treatment of sepsis wound (ulcer)  dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis  depression, acne, decreased wound healing, moon face, buffalo hump, anorexia, nausea, muscle-wasting, osteoporosis, hypertension.  Arrhythmias, abdominal pain, diarrhea, n/v.  Chest pain, palpitations, nervousness, restlessness, tremor  Erectile dysfunction, fatigue, weakness, hypotension, bradycardia.  Burning, itching, pain, rash, skin discoloration, necrosis. © 2023 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

Part I: Developing Noticing and Interpreting Skills

Present Problem Jack Holmes is a 72-year-old male brought to the emergency department (ED) by ambulance from a skilled nursing facility (SNF). According to report from the paramedic, when the SNF nursing staff attempted to wake him this morning, he would not respond and his BP was 74/ with a MAP of 51. He has a history of Parkinson’s disease, COPD, CHF, HTN, depression, and stage IV decubitus ulcer on his coccyx that developed three months ago. He does not follow commands, is unresponsive to verbal stimuli, but responds to a sternal rub with grimacing and withdrawing from stimulus. He has no known allergies. Personal Social History He has lived in the skilled nursing facility for the past three years and has been bed bound for the past year due to his advanced Parkinson’s disease. He was a heavy smoker, 1 PPD, for 40 years until he moved to the SNF. He is estranged from his only family member, a daughter, who is also his power of attorney for health care. He does not have a DNR order but has told his care providers previously to “leave me alone and let me die.” Contextual Factors Your clinical assignment is in a medium-sized community hospital. They function without unlicensed assistive personnel, so nursing staff provides all the care for clients. You follow your client for the rest of the shift whether he stays in the ED or gets transferred to another unit. The ED is really busy, with 10 people waiting in the waiting room and so you need to make decisions quickly! The ICU at this hospital can take clients on pressors and ventilators. Still, anyone requiring extensive interventions (i. hemodialysis or Intraaortic balloon pump) will need to be transferred to a larger metropolitan hospital.

• Which findings from the present problem are most important and noticed by the nurse as clinically significant? Provide a rationale for your answer(s). Most Important Findings Clinical Significance  BP was 74/4 with a MAP of 51  History of Parkinson’s disease, COPD, CHF, HTN, depression, and stage IV decubitus ulcer on his coccyx that developed three months ago  unresponsive to verbal stimuli but responds to a sternal rub with grimacing and withdrawing from stimulus  Bottomed-out BP indicates septic shock  Hx of COPD and CHF compromise O2 and tissue perfusion  Ulcer offers a portal of entry for infection  CPR is not needed as he is responsive to sternal rub.
• Which data from the social history is most important and noticed by the nurse as clinically significant? Provide a rationale for your answer(s). Most Important Findings Clinical Significance  Has lived in SNF for 3 years and has been bedbound for the past year due to advanced Parkinson’s.  Estranged from his daughter, who is also his POW.  40-year heavy smoker (1 ppd).  Alone/no family support  Diminished independence could be a leading cause of depression diagnosis.  History of smoking contributes to lung and vascular damage.

Client Care Begins

• Which current vital sign findings are most important and noticed by the nurse as clinically significant? Provide a rationale for your answer(s) Most Important Data Clinical Significance  BP 76/39 (MAP 51)  Pulse 39  Temp 101 F  SpO2 91%  Resp 32/min on 2L O2 per NC  Compromised O2 sat and tissue perfusion  Increased HR (risk for arrhythmias)  Increased Temp signs of infection and septic shock  High risk for organ failure  Insufficient SpO Current Assessment General Survey Pale and cool to touch Pain Not responsive verbally, withdraws to pain, no other indicators of pain Neurological Does not open eyes to sound or pain, withdraws to pain, incomprehensible sounds to painful stimuli, does not follow commands but does not resist when moved on a stretcher. PERRL Head Head normocephalic with symmetry of all facial features. Pupils brisk, reactive to light, sclera white bilaterally, conjunctival sac pink bilaterally. The lips, tongue, and oral mucosa are pale and moist. Respiratory Tachypneic and working hard to breathe, intercostal and suprasternal retractions present. Breath sounds diminished and light crackles in lower lobes bilat. Nail beds have a noticeable clubbing, barrel chest present. Cardiac Pale, 1+_pitting edema lower extremities, with an irregular rhythm, radial pulses weak by doppler, capillary refill 5 seconds Abdomen Distended abdomen, firm/nontender, bowel sounds hypoactive in all gradients Genitourinary Urinary catheter placed to monitor urine output. 50 mL tea-colored urine with no sediment and no odor present

Integumentary Stage IV decubitus to coccyx 1 cm x 0 cm x 0 cm depth, wound bed with visual bone noted at the base with large areas of necrosis on both sides of the sacrum bone. When dressing was removed a large amount of yellow/green purulent drainage on dressing with foul odor. Mucus membranes dry and pale. 6. What assessment data needs to be noticed as most important? Interpret its clinical significance. Most Important Data Clinical Significance  GCS – 4  Tense, pale, and warm to touch  Tachypneic with crackles  +1 pitting edema  Systolic murmur, irregular rhythm,  radial pulses weak and thready, cap refill 3 sec.  Distended abdomen, firm, hypoactive  Visible necrosis, purulent drainage, can see to the bone on his ulcer.  50 ML tea-colored urine, no segments, no odor  Not following commands, unresponsive, uncomprehending sounds with painful stimuli  severe brain injury (score 3-8)  CHF (heart does not pump effectively)  Fluid on lungs and in the abdomen (may need to be mechanically ventilated).  Trying to blow off some CO2, get oxygen, trying to maintain gas exchange.  GI system shuts down to send blood to the main organs, such as the brain and heart.  Neglect (ulcer has not properly been cared for) ossible liver and kidney failure. Body is trying to save the mayor organs, shunting out blood from non-important organs like kidney and liver. ossible liver and kidney failure. Body is trying to save the mayor organs, shunting out blood from non-important organs like kidney and liver.  Possible liver and kidney failure. The body is trying to save the major organs, shunting out blood from non-important organs like the kidney and liver.

Auscultate Posterior Breath Sounds

Place a circle on the chest where the nurse would place the stethoscope to auscultate the right lower lobe. Click twice on the symbol to listen Lung Auscultation Identify what type of breath sounds are heard and interpret their clinical significance. Breath Sounds Clinical Significance Breath sounds diminished and light crackles Typical for COPD patients.

• Which findings from this new information are most important and noticed by the nurse as clinically significant? Most Important Findings Clinical Significance Nurse Response  Heart tones (bradycardia)  Pressure Ulcer (coccyx)  Lung sounds (associated with COPD)  Decreased cardiac output/perfusion.  Portal of entry  Higher risk of infection due to weaker infection.

#######  Monitor cardiovascular status

#######  Monitor for infection

#######  Monitor lung sounds

The nurse precepting you says, &quot;I&#039;m pretty sure

This client meets the sirs (systemic, inflammatory response syndrome) criteria, and, we should be starting the sepsis protocol.&quot;.

• Identify which of the above assessment data satisfies the SIRS criteria SIRS Criteria Clinical Significance Nurse Response  BP 76/39 (MAP 51)  Pulse 39  Temp 101 F  SpO2 91%

#######  Resp 32/min on 2L O2 per NC

 Compromised O2 sat and tissue perfusion  Increased HR (risk for arrhythmias)  Increased Temp signs of infection and septic shock  High risk for organ failure

#######  Insufficient SpO

#######  Monitor vitals for improved or

worsening condition.

#######  Monitor airway, breathing, and

circulation.

####### 9. Recognizing a potential problem, you use Identify-Situation-Background-Assessment-

####### Recommendation (ISBAR) to update the provider. Summarize what you would communicate to

####### address your concern effectively.

I identify Specify who you are/where you work.

 Yourself: name/position/location  Client: name/age/gender  Summer/student nurse/WVJC  Jack Holmes/72-years-old/Male

S situation

What is the problem/reason for contact? Concise summary of primary problem:  Unresponsive, BP 70/40 (MAP 51); does not follow commands and is unresponsive to verbal stimuli; responds to sternal rub with grimacing and withdrawing from stimulus.

B background If urgent, state concern. Provide concise/relevant history

 Primary problem/diagnosis:  Day of admission/post-op day #:  Relevant past medical history:  Relevant treatments/interventions:  Sepsis  Day of admission/post-op day: 12 hours  History: COPD, CHF, Parkinson’s depression, pressure ulcer on coccyx, smoker.

A assessment

Assessment of the situation using the most important clinical data. State your concern by communicating concerning clinical data:  Vital signs  Nursing assessment  Lab/diagnostic results Trend of most important clinical data (stable-increasing/decreasing):  BP 76/39 (MAP 51), Pulse 39, Temp 101 F, SpO2 91%, Resp 32/min on 2L O2 per NC  GCS – 4; Tense, pale, and warm to touch; Tachypneic with crackles; + pitting edema; Systolic murmur, irregular rhythm, ; radial pulses weak and thready, cap refill 3 sec.; Distended abdomen, firm, hypoactive; Visible necrosis, purulent drainage, can see to the bone on his ulcer; 50 ML tea- colored urine, no segments, no odor

R recommendation Request specific advice/interventions. Clarify expectations.

Nurse suggestions to advance the plan of care: What do you recommend? Repeat and state back new orders/confirm plan of care:  Chest x-ray or CT scan  Labs

Priority Setting

• Determine the order of priority the nurse will implement each order and the rationale for the order you chose. Care Provider Orders: Order of Priority: Rationale for Order of Priority  2 large bore (18 g) IVs  Vancomycin 2 gram IV after cultures collected  Clindamycin 600mg IV every 6 hours  Fluid bolus 0% NS 30 mL/kg (2250 mL)  Blood cultures, urine cultures, wound culture  Cardiac telemetry  VS every 5-15&quot;  Acetaminophen 1000 mg PR every 6 hours PRN for temp &gt;
• Large bore IVs
• Cardiac telemetry
• VS every 5-
• Blood, urine, and wound cultures.
• Fluid bolus NS
• Acetaminophen

Clindamycin

• Vancomycin  Access to administer meds and fluids  Monitoring to detect changes that could be life-threatening  To monitor BP and O2 to detect changes  Obtain cultures and sent to lab for results for antibiotic tx  Fluid restoration  Tx elevated temperature  1 st line antibiotic  2 nd line antibiotic For the order of norepinephrine continuous infusion, complete the table below. Mechanism of Action Most Common Side Effects Priority Assessments Pt. Education Stimulates alpha-adrenergic receptors located mainly in blood vessels, causing constriction of both capacitance and resistance levels. Also has minor beta-adrenergic activity (myocardial stimulation).  Neuro: anxiety, dizziness, headache, insomnia, restlessness, tremor, weakness.  Resp: dyspnea.  CV: arrythmia, bradycardia, chest pain, HTN.  GU: decreased UOP, renal failure  Endo: hyperglycemia  F &amp; E: metabolic acidosis  Local: phlebitis at IV site  Misc.: fever  Monitor BP every 2- min until stable and every 5 min thereafter.  Continuous ECG monitoring  Monitor UOP  Assess IV site.  Monitor for toxicity and overdose.  Explain purpose of med  Instruct patient to report headache, dizziness, dyspnea, chest pain, or pain at infusion site promptly.  Instruct patent to notify physician if pregnant (Female). For the new order of vasopressin continuous infusion, complete the table below. Mechanism of Action Most Common Side Effects Priority Assessments Pt. Education Alters permeability of the renal collecting ducts, allowing reabsorption of water. Directly stimulates musculature of GI tract. In high doses, acts as a peripheral vasoconstrictor.  CV: MI, angina, chest pain  Derm.: paleness, perioral blanching, sweating.  Endo: diabetes insipidus  F &amp; E: water toxicity  GI: abdominal cramps, belching, diarrhea, flatulence, heartburn, nausea, vomiting.  Neuro: trembling, dizziness, “pounding” sensation in head  Local: phlebitis at IV site  Misc.: allergic reaction, fever  Monitor BP, HR, ECG continuously throughout cardiopulmonary resuscitation.  Monitor serum electrolyte levels.  Monitor for toxicity and overdose  Explain purpose of med  Advise patient to drink 1- glasses of water with each administration to minimize side effects.  Inform patient of the side effects.  Caution against concurrent use of alcohol.  Advice patient to notify physician of pregnancy or breastfeeding (Female).

Dosage Calculation: Vancomycin 2 g IVPB

Medication Time frame to Administer Show Work Rate to Deliver Vancomycin Concentration : 2 g/400 mL Usual Adult Dose for Sepsis 500 mg IV every 6 hours OR 1 g IV every 12 hours This drug should be administered at a rate of up to 10 mg/min or over 1 hour, whichever is longer. 500 mg/100 mL Hourly Rate on IV Pump: Manual Drip Rate per/minute:

Dosage Calculation: Clindamycin 600 mg IVPB

Medication Time frame to Administer Show Work Rate to Deliver

Concentration: 600 mg/50mL

Serious infection: 600 to 1,200 mg via IV infusion or Severe infection: A single 1 hour IV infusion greater than 1,200 mg is not recommended

####### Hourly Rate on IV Pump:

####### Manual Drip Rate per/minute:

Lab Results

Hematology: Complete Blood Count (CBC) WBC HGB PLTS %Neuts %Lymphs %Monos %Eosin Bands Range 4-11 mm 3 12-16 g/dL 150-450 x 10 3/μL 55-70 20-40 2-8 1-4 0-2% Current 15! 13 229 88! 10! 2 1 10! Prior adm. 10 13 210 65 22 4 2

####### 12. Which diagnostic findings are most important and noticed by the nurse as clinically significant?

Most Important Data Clinical Significance (provide rationale) TREND Improved/Declined/No Change  WBC 15.  Neutrophils: 88%  Lymphocytes:  Bands: 10 %  Elevated WBC indicates infections.  Elevated neutrophils support evidence of infection  Low lymph’s support evidence of infection  Elevated bands indicate SIRS.  Declined  Declined  Declined  Declined Metabolic Panel Na K Cl CO2 AG Gluc CA BUN Create GFR Range 135- mEq/L 3-5. mEq/L 95- mmol/L 20- mmol/L 7- mEq/L 64- mg/dL 8-10. mg/dL 8- mg/dL 0-1. mg/dL &gt; mL/min Current 148! 5 98 22 12 168! 9 38! 1! 50! Prior adm. 139 4 95 20 10 109 8 22 0 60 13. Which diagnostic findings are most important and noticed by the nurse as clinically significant? Most Important Data Clinical Significance TREND Improved/Declined/No Change  Na+: 148  K+: 5.  Gluc.: 168  BUN: 38  Cr.: 1.  GFR: 50  Kidney failure can contribute to increased sodium levels, which can cause arrythmias.  Failing kidneys retain potassium and increased potassium can lead to arrhythmias.  Hyperglycemia caused by septic shock.  Kidneys failing/not functioning properly.  Kidneys failing/not filtering properly because of decreased perfusion.  Declined  Declined  Declined  Declined  Declined  Declined

Mg COVID- 19 `Ion Ca Lipase Lactate (Ven) Hgb A1C Range 1.6-2 Eq/L Neg 1.03-1 mmol/L 3-73 units/L 0.5-2 mmol/L &lt;5% Current -- -- -- -- 6! --

• Which diagnostic findings are most important and noticed by the nurse as clinically significant? Most Important Data Clinical Significance

Lactate (lactic acid) builds up due to the cells going through anaerobic

Metabolism because of the decreased oxygen, resulting from poor.

Liver Panel Albumin Ammonia Total Bili Direct Bili Indirect Bili Alk Phos ALT AST Range 3- g/dL 35- mcg/dL 2-20 μmol/L 0-6 μmol/L 0 to 1 mg/dL 500- U/L 5- U/L 5- U/L Current 2! 59 38! -- -- 148! 145! 152! Prior adm. 3! 42 9 -- -- 52 15 20 15. Which diagnostic findings are most important and noticed by the nurse as clinically significant? Provide a rationale for your answer(s). Most Important Data Clinical Significance TREND Improved/Declined/No Change  Albumin: 2.  Total Bili: 38  Alk: 148  ALT/AST: 145/  Failing liver due to decreased perfusions  Failing liver creating excess bile in the body, which can back up in the liver and release into the bloodstream.  Elevated Alk causes a decrease in the liver’s ability to break up proteins, indicating liver failure.  Elevated liver enzymes indicate the liver is not functioning properly or failing.  Declined  Declined  Declined  Declined Urinalysis Color Clarity Sp Grav pH Protein Glucose Ketones Bili Blood Nitrate LET Range Pale Yellow Clear 1.016-1 4.5-7 Neg &gt;0 g/day Neg Neg &lt; 3 cells Neg Neg Current Tea! Clear 1! 6 Neg Neg Neg Neg 0 Neg Neg RBC s WBCs Bacteri a Epithelia l Reference Range 0- cells 0-5 cells 0-few 0-few Current 0 2 0 few UA Micro

Nursing Management of Care

After interpreting clinical data collected, identify the nursing priority and three priority interventions. For each intervention write the rationale and expected outcome. Nursing Priority Improved tissue perfusion Priority Intervention(s) Rationale Expected Outcome  Fluid therapy  Administer vasopressors if hypotensive  Administer antibiotics  Administer pain medication  Monitor vitals, AGBs, Respiratory status, LOC, and labs (especially PT, AST, BUN, Lactate)  Monitor I&amp;O  Increased volume to improve cardiac output, BP, and tissue perfusion.  Once fluid is increased, vasopressors will help BP, CO, and tissue perfusion.  Fight infection  Physical and psychological comfort  Constant monitoring to detect changes immediately and/or reevaluate current treatment plan.  Fluid status  Increase fluid volume to help BP, CO, and tissue perfusion.  Increase oxygen in the blood and perfusion.  Client becomes stable and prognosis looks better.  Decreased pain and anxiety.  Ceased progression.  Properly functioning kidneys.

Identify the psychosocial/holistic care priority based on the findings you noticed as most important. List appropriate interventions, rationale, and expected outcomes. Psychosocial/Holistic Care Priority Communication (unresponsive or not) Priority Interventions Rationale Expected Outcome  Therapeutic communication  Speak in a kind, respectable tone  Let the client know everything you are doing.  Involve the family in his care  Establish and build rapport and trust with the patient and family.

Problem Recognition

####### 5. To prevent a complication based on the primary problem, answer each question in the table below.

Identify the most likely and worst possible complications.

####### Most Likely/ Worst Possible

(Multiple organ dysfunction failure)

What interventions can prevent them from developing? Monitoring BP and pulse, monitoring labs, and monitoring LOC. What clinical data/assessments are needed to identify them early? A decrease in BP, increase in lactate, changes in ABG values, and decreased LOC. What nursing interventions will the nurse implement if the anticipated complication develops? Administer IV fluids, possible vasopressor administration; monitor labs closely/frequently for changes and notify physician immediately if any changes occur.

• Which interprofessional team member would the nurse need to consult and collaborate with to promote and maintain health after discharge?

Team Member Rationale

 Wound care  Physical therapy  Dietician/nutritionist  Teach the client/family how to properly care for his wound and prevent future pressure ulcers.  Promote ambulation and physical activity and assist with range of motion and ADLs.  Encourage good nutrition and hydration to protect the immune system and aid in wound healing.

Part III: Developing Evaluation

• For each finding, make a clinical judgment by placing an &quot;x&quot; in the appropriate column if the client&#039;s condition has improved, has not changed, or has declined.

####### Assessment Finding Improved No Change Declined

T: 101 F/38 C (oral) X P: 124 (irregular) X R: 24 (regular) X BP: 86/56 MAP: 66 X O2 sat: 93% 2 liters n/c X Opens eyes to voice, obeys simple commands X Serum lactate decreased from 6 to 4 X

Two hours later...

The client received 2,250 ml 0% ns, and a right internal jugular central line was placed in the, ed. he was transferred to the icu an hour ago and appeared to rest comfortably., he has required norepinephrine 6 mcg/min to maintain a map &gt;65., vital signs one hour ago:,  t: 101 f/39 c (oral),  p: 125 (irregular),  r: 32 (regular),  bp: 76/39 map: 51,  o2 sat: 91% 2 liters n/c, 2. is the overall status of the client:, current status rationale, a. improved, b. no change, c. declined, decreased lactate, improved o2 sat, increased bp and map, and decreased respirations indicate the, patient is status is improving and trending in the right direction., 3. after evaluating the client, identify the current nursing priority and which action(s) the nurse should take. list, interventions by priority and the expected outcome., nursing priority tissue perfusion, priority interventions rationale expected outcome,  monitor for arrhythmias,  detect unexpected changes, and to see if pt, is progressing and improving with current,  reduce temperature,  decrease risk of hf,  client status maintained or, continuing to improve,  temp wnl/reduced risk, for neuro damage..

• Multiple Choice

Course : Critical Care Nursing/Lab/Clinical (NUR 207)

University : west virginia junior college.

• Discover more from: Critical Care Nursing/Lab/Clinical NUR 207 West Virginia Junior College 4   Documents Go to course
• More from: Critical Care Nursing/Lab/Clinical NUR 207 West Virginia Junior College 4   Documents Go to course

Sepsis and Septic Shock

Sepsis and septic shock stand as life-threatening conditions that demand swift and vigilant action from healthcare providers, with nurses playing a pivotal role in their management. As frontline caregivers , nurses are essential in recognizing early signs of sepsis, initiating prompt interventions, and providing comprehensive care to improve patient outcomes .

This article aims to highlight the critical importance of nursing in battling sepsis and septic shock, shedding light on the pathophysiology, risk factors, clinical presentations, and evidence-based interventions. By fostering a comprehensive understanding of these conditions, nurses can proactively contribute to saving lives and minimizing the burden of sepsis on patients and healthcare systems.

Table of Contents

What is sepsis and septic shock , pathophysiology, epidemiology, clinical manifestations, complications, assessment and diagnostic findings, medical management, nursing assessment, planning & goals, nursing interventions, discharge and home care guidelines, documentation guidelines.

One of the most common types of circulatory shock and the incidences of this disease continue to rise despite the technology.

• Sepsis is a systemic response to infection . It is manifested by two or more of the SIRS (Systemic Inflammatory Response Syndrome) criteria as a consequence of documented or presumed infection.
• Septic shock is associated with sepsis. It is characterized by symptoms of sepsis plus hypotension and hypoperfusion despite adequate fluid volume replacement.

The pathophysiology of sepsis involves an evolving process. The following shows the process of how sepsis works its way inside of our body.

• Microorganisms invade the body tissues and in turn, patients exhibit an immune response.
• The immune response provokes the activation of biochemical cytokines and mediators associated with an inflammatory response.
• Increased capillary permeability and vasodilation interrupt the body’s ability to provide adequate perfusion, oxygen , and nutrients to the tissues and cells.
• Proinflammatory and anti-inflammatory cytokines released during the inflammatory response and activates the coagulation system that forms clots whether or not there is bleeding .
• The imbalance of the inflammatory response and the clotting and fibrinolysis cascades are critical elements of the physiologic progression of sepsis in affected patients.

Sepsis has affected a lot of people in the United States and around the world as well. The rise in the numbers of those affected with sepsis is alarming and should be given utmost attention.

• Annually, an estimated 750, 000 people in the United States are affected by sepsis.
• By 2010, the rate may increase up to 1 million cases every year.
• Elderly patients are at most risk for developing sepsis because of decreased physiologic reserves and an aging immune system.
• Gram-positive bacteria accounts for 50% of cases of septic shock.
• It is also estimated that 20% to 30% with severe sepsis may never identify the site of infection.

There are several factors that can put the patient at risk for septic shock, and these include:

• Patients with immunosuppression have greater chances of acquiring septic shock because they have decreased immune system, making it easier for microorganisms to invade the body tissues.
• Extremes of age. Elderly people and infants are more prone to septic shock because of their weak immune system .
• Malnourishment . Malnourishment can lower the body’s defenses, making it susceptible to the invasion of pathogens.
• Chronic illness. Patients with a longstanding illness are put at risk for sepsis because the body’s immune system is already weakened by the existing pathogens.
• Invasive procedures. Invasive procedures can introduce microorganisms inside the body that could lead to sepsis.

The signs and symptoms that are associated with septic shock and sepsis include the following:

• Since the ability of the body to provide oxygen and nutrients is interrupted, the heart compensates by pumping faster.
• Hypotension occurs because of vasodilation .
• To compensate for the decreased oxygen concentration, the patient tends to breathe faster, and also to eliminate more carbon dioxide from the body.
• The inflammatory response is activated because of the invasion of pathogens.
• Decreased urine output. The body conserves water to avoid undergoing dehydration because of the inflammatory process.
• Changes in mentation . As the body slowly becomes acidotic, the patient’s mental status also deteriorates.
• Elevated lactate level. The lactate level is elevated because there is maldistribution of blood .

Before sepsis could invade a patient’s body, it is better to prevent its occurrence here are some ways to prevent sepsis and septic shock.

• Strict infection control practices. To prevent the invasion of microorganisms inside the body, infection must be put at bay through effective aseptic techniques and interventions.
• Prevent central line infections . Hospitals must implement efficient programs to prevent central line infections, which is the most dangerous route that can be involved in sepsis.
• Early debriding of wounds. Wounds should be debrided early so that necrotic tissue would be removed.
• Equipment cleanliness. Equipment used for the patient, especially the ones involved in invasive procedures, must be properly cleaned and maintained to avoid harboring harmful microorganisms that can enter the body.

Complications could happen in a patient with sepsis if it is not properly treated or not treated at all.

• Severe sepsis. Sepsis could progress to severe sepsis with symptoms of organ dysfunction, hypotension or hypoperfusion, lactic acidosis, oliguria, altered level of consciousness, coagulation disorders, and altered hepatic functions.
• Multiple organ dysfunction syndrome . This refers to the presence of altered function of one or more organs in an acutely ill patient requiring intervention and support of organs to achieve physiologic functioning required for homeostasis .

Early assessment and diagnosis of the infection must be established to avoid its progression.

• Blood culture. To identify the microorganism responsible for the disease, a blood culture must be performed.
• Liver function test. This should be performed to detect any alteration in the function of the liver.
• Blood studies. Hematologic test must also be performed to check on the perfusion of the blood.

The current treatment of septic shock and sepsis include identification and elimination of the cause of infection.

• Fluid replacement therapy . The therapy is done to correct the tissue hypoperfusion, so aggressive fluid resuscitation must be implemented.
• Nutritional therapy . Aggressive nutritional supplementation is critical in the management of septic shock because malnutrition further impairs the patient’s resistance to infection.

Nursing Management

Nurses must keep in mind that the risks of sepsis and the high mortality rate associated with sepsis, severe sepsis, and septic shock.

Assessment is one of the nurse ’s primary responsibilities, and this must be done precisely and diligently.

• Signs and symptoms . Assess if the patient has positive blood culture, currently receiving antibiotics , had an examination or chest x-ray , or has a suspected infected wound.
• Signs of acute organ dysfunction . Assess for presence of hypotension, tachypnea , tachycardia, decreased urine output, clotting disorder, and hepatic abnormalities.

Sepsis can affect a lot of body systems and even cause their failure, so diagnosis is an important part of the process to establish the presence of sepsis.

• Risk for deficient fluid volume related to massive vasodilation.
• Risk for decreased cardiac output related to decreased preload .
• Impaired gas exchange related to interference with oxygen delivery.
• Risk for shock related to infection.

Healthcare team members should be prepared with a care plan for the patient for a more systematic and detailed achievement of the goals.

• Patient will display hemodynamic stability.
• Patient will verbalize understanding of the disease process.
• Patient will achieve timely wound healing .

Nursing interventions pertaining to sepsis should be done timely and appropriately to maximize its effectivity.

• Infection control . All invasive procedures must be carried out with aseptic technique after careful hand hygiene .
• Collaboration . The nurse must collaborate with the other members of the healthcare team to identify the site and source of sepsis and specific organisms involved.
• Management of fever . The nurse must monitor the patient closely for shivering.
• Pharmacologic therapy . The nurse should administer prescribed IV fluids and medications including antibiotic agents and vasoactive medications.
• Monitor blood levels . The nurse must monitor antibiotic toxicity, BUN, creatinine , WBC, hemoglobin , hematocrit, platelet levels, and coagulation studies.
• Assess physiologic status . The nurse should assess the patient’s hemodynamic status, fluid intake and output , and nutritional status .

After implementation of the interventions, the nurse must evaluate their effectiveness.

• Patient displayed hemodynamic stability.
• Patient verbalized understanding of the disease process.
• Patient achieved timely wound healing .

Even after discharge, the patient must still be taught how to establish home and community care regimen.

• Prevent shock episodes . The nurse should instruct the patient and the family strategies to prevent shock episodes through identifying the factors implicated in the initial episodes.
• Instructions on assessment . The patient and the family should be taught about assessments needed to identify the complications that may occur after discharge.
• Treatment modalities . The nurse must teach the patient and the family about treatment modalities such as emergency administration of medications, IV therapy , parenteral or enteral nutrition , skin care , exercise, and ambulation .

Proper documentation must be established both for legal protection and data organization.

• Document individual risk factors.
• Document assessment findings.
• Document results of the laboratory tests and diagnostic studies.
• Document plan of care and teaching plan.
• Document client’s responses to treatment, teaching, and actions performed.
• Document modifications in the plan of care.

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• Risk for Infection

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Septic shock: a case study

• PMID: 8696026
• DOI: 10.1016/s0964-3397(96)81713-7

Septic shock is a pathological process that is common to most intensive care units; however, despite major developments in intensive care and medicine, it continues to be one of the commonest causes of morbidity and mortality. This article describes the management of a patient admitted to intensive care with septic shock. Some of the principles regarding septic shock, including the pathophysiology, management and nursing care, are explored. Also included are some of the current theories and research into the sepsis syndrome.

Publication types

• Case Reports
• Acute Disease
• Critical Care / methods*
• Pancreatitis / complications*
• Shock, Septic / etiology
• Shock, Septic / nursing*
• Shock, Septic / physiopathology