SEPTIC SHOCK

This assignment concerns case three – Septic shock. Douglas, a 70 years old male patient, is admitted to the emergency department after four days of illness, with nausea and vomiting. Septic shock is a severe and often fatal condition caused by sepsis. Sepsis is a result of a localized or widespread infection, which causes organ failure and life-threatening low blood pressure (Gauer, 2016 p.44). It develops through three stages – sepsis, severe sepsis, and septic shock.

Systemic Review

At the time of admission, Douglas weighed 88 kgs and had T39, HR 120, RR 24, BP, 90/60, and his oxygen sats are 92%. He has a GCS of 15, he has not opened his bowels for four days and has abdominal distention. The general abdominal pain is 7/10.

CNS: This involved a laboratory test – cerebrospinal fluid analysis to check the possible damage of the CNS. In this case, encephalopathy and periphery neuropathy were a positive test for septic shock. Although the prognosis of septic shock and CNS is poorly developed thus far, damage to the CNS due to septic shock may reveal as meningitis and encephalitis. The patients experienced lethargy, confusion. His GCS^d score was then seven.

CVS: The CVS is critical assessment criteria, from which the functioning of the heart and blood vessels were reviewed. The patient’s blood pressure was 90/60, which was caused by a reduced vascular tone. An ECG revealed a low yet normal rhythm for the heartbeat. According to Kalil (2019), septic shock leads to impaired secretion of vasopressin, hence vasodilation. Other results were hemodynamic status: SBP 88 mm Hg, MAP 68 mm Hg. The complete blood count reveals a decreased count of 3.60 trillion cells/L, 3.0 billion cells/L, and 120,000 per microliter for RBC, WBC, and platelets, respectively.

RESP: Concerning the respiratory system, the gas test showed that his oxygen sats are 92%. Lab tests revealed arterial hypoxemia of PaO2/FIO2< 250 since Douglas is not pneumonic (Gauer, 2016 p.45). Besides, the patient has pulmonary dysfunction, which is identified as inflammatory cytokines and chemokines. Also, among the identified organ failures, Douglas has an acute respiratory distress syndrome. A chest inspection revealed low air entry, which had caused short breaths.

ABDO: The patient had abdominal pains of 7/10. The presence of ileus and nosocomial pneumonia were reviewed since they are criteria for septic shock. Overgrowth of infections in the upper gut had not yet led to aspiration into the lungs, but the patient was at risk of nosocomial pneumonia. Also, the patient had low glutamine levels, which further led to decreased leukocyte count recorded during the complete blood count.

RENAL: Renal tests helped identify whether the source of infections in the urinary tract. In this case, part of the liver was damaged, probably due to prolonged alcoholism, which progressed sepsis. Besides, the patient had renal damage, as a septic shock is accompanied by renal failure (Kalil, 2019). The expected results in the case of oliguria – urine output was < 0.5mL/kg/hr for ≥2 hr, which presumptively suggests the presence of septic induced renal failure (Kalil, 2019).

Other tests: Other tests included the gram stain and cultures, which entail detecting the presence of bacteria or other infectious microbes. Although not very definitive, the presence of any type of a bacterium would lead to presumptive results for septic shock. Some of the findings included Staphylococcus aureus, Escherichia coli, Anaerobes, Gram-negative bacteria, which were found from the test. A similar test is the blood cultures, from which septicemia was detected. Lactate may help identify organ dysfunction; thus, it was useful in tracking the localized infections in the kidneys, the liver, lungs, and vesicular system. Besides, a comprehensive metabolic panel helped review the health of organs and monitor the blood glucose and electrolyte balance.

Priorities of Treatment

According to the National Institute for Health and Care Excellence (NICE), there are six treatment priorities for septic shock.

Blood Test: The immediate treatment procedure after admission to the emergency department was blood tests. They involve obtaining lactate levels. According to Kalil (2019), the severity of septic shock is parallel to the level of lactate in the blood. Thus, the assessment of the lactate level provided useful information pertaining to the severity of septic shock and in monitoring the progression of the treatment. Consequently, a registered nurse should take tests regarding CBC, blood cultures, CRP, urea, and electrolytes (Davis, Langmack, and Wood, 2017). The CBC helped in detecting the overall health status of Douglas, which entailed nullifying the presence of illnesses such as anemia, leukemia, and a range of disorders. Also, a registered should record the CBC, noting the amount of RBC, WBC, and platelets. That is in line with the roles of a registered nurse; that is, assessment and documentation of the health status of a patient (Smolowitz et al., 2015 p.4). Nevertheless, an RN must ensure that they develop and follow a nursing care plan throughout the treatment.

Tests regarding blood cultures are critical to identifying the presence of any bacteria or other infectious agents such as yeast and microorganisms. They were conducted to assess the presence of septicemia or other health complications. Also, a c-reactive protein (CRP) test was conducted to measure the amount of CPR released into the bloodstream from the liver due to inflammation (Sproston and Ashworth, 2018 p.2). The amount of CRP helped to assess the severity of the septic shock. For instance, in acute infections or disorders, the level of plasma CRP increases by 25% (Sproston and Ashworth, 2018, p.2). The renal test (urea tests) is crucial since septic shock may be aggravated by renal health. Thus, it was conducted to identify whether the sepsis is a consequence of an acute kidney injury (Bilgili, Haliloglu, and Cinel, 2015 p.294).

Early Antibiotics: A registered nurse administered antibiotics after taking blood tests. Usually, broad-spectrum antibiotics for both Gram-positive and Gram-negative bacteria are used (Kalil, 2019). The urgency for this treatment depends on the severity of the illness. For instance, if the patient is at high risk, the antibiotics should be administered with the first hour of admission; else, if moderate, they should be administered within three hours (Davis, Langmack and Wood, 2017). Thus, the antibiotics were administered within one hour after admission. As per the roles of a registered nurse, this is a diagnostic approach to the patient’s illness, since one has to ascertain bacterial infections from the tests in the priority number one. Besides, one of the roles of an RN is to administer mediations and treatment (Yolanda Smith, 2019, par.1).

Fluid Status (perfusion): Perfusion priority comprised of two steps; first, a fluid resuscitation, and secondly, monitoring of urine output. According to Kalil, patients require “30 mL/kg of crystalloid solution for hypotension or lactate levels of 4 mmol/L or higher” (2019). She adds that the value of 30 mL/kg is the average value that was derived from the fluid resuscitation of septic shock classes (Kalil, 2019). Therefore, the patient – Douglas was assessed to decide whether to administer more or less the value 30mL/kg. However, a better approach was to administer the fluid in relation to the response of the patient to the resuscitation. This was done for between ten and fifteen minutes. The registered nurse was diligent, executing their role through monitoring and assessment of the progress of the patient’s health outcome.

Additionally, the registered nurse conducted a catheterize as necessary. All patients of septic shock should have a urinary catheter (Davis, Langmack, and Wood, 2017). The urinary output should be monitored, making sure the adequate renal perfusion and cardiac output are maintained (Kalil, 2019). The normal urine output should be more than 0.5 mL/kg/hr in adults. A lesser value indicates complications in blood pressure. Thus, an RN assessed the blood volume and cardiac output to correct any abnormalities.

Observation of Vital Signs: A registered nurse kept on monitoring and recording the vital signs of the patients, such as the body temperature, heart rate, and breathing (Davis, Langmack and Wood, 2017). They noted that if the patient has breathing difficulties, they may be aided through intubation and mechanical ventilation. Notably, some studies have found that the “performance of a physical examination for signs and symptoms of infection and may require focused ultrasonography to recognize more complex physiologic manifestations of shock” (Seymour and Rosengart, 2015 p.2). Registered nurses should thus do due diligence in ensuring the health condition of a patient does not deteriorate through monitoring.

Oxygen Delivery: As noted above, a patient with difficulties in breathing should be helped through intubation and mechanical ventilation. The registered nurse and assisting practitioners to ensure that Douglas received an oxygen saturation level to keep his SpO₂ within 94% to 98% (Seymour and Rosengart, 2015 p.3; Kalil, 2019). Kalil further notes that cardiac output in patients suffering sepsis shock is maintained with volume-resuscitated sepsis. In some cases, inotropic therapy and augmented oxygen delivery are used. Also, nurses must understand the signs in the delivery of oxygen, such as the inability to increase oxygen consumption rate for patients suffering from septic shock. This is caused by impaired oxygen extraction or irreversible anaerobic metabolism due to organ injury (Kalil, 2019). Note that for patients with chronic obstructive pulmonary disease records, and oxygen saturation level of 88% to 92% (Davis, Langmack, and Wood, 2017).

Infection Screening: In this priority, a registered nurse assessed Douglas’ possible chance to infect other ward users, for instance, through coughs, urine, and leaking wounds. This is part of a registered nurses’ role to ensure safe and efficient nursing practice through the management and supervision of other staff (Smolowitz et al., 2015 p.5). In other words, registered users must ensure the patient does not pose any risk of infection to health practitioners and other patients.

Discharge Planning

Discharge planning is the process where a nurse identifies the healthcare needs of a patient after they have left the hospital, and organized with them and caregivers on how to meet the needs. A discharge plan had begun as early as during the admission of Douglas. At that time, a nurse identified the caregivers who would be at home looking after Douglas once discharged. In this case, Douglas has no children and is divorced. Therefore, a nurse had to reach put to other family members such as parents and siblings. They were informed of the discharge procedure and put at ease to raise any concerns. This aligns with the social justice framework, which advocates access and equitable access to services.

During the stay at the hospital, the caregivers and the patient were educated about the septic shock and its associated health outcomes. Using the teach-back, both the patient and the caregivers learned medications involved and their administration. Also, a nurse informed them of the care practices that shall be done at home. This was in line with the participatory goal of the social justice framework, which ensures patients take part in their treatment process, such as in decision making.

Before discharge, Douglas and his caregivers were informed of the transition from hospital to home. This involved a meeting with the caregivers and the patient so that they can make prior arrangements. The registered nurse informed them about the follow-up appointments for Douglas after the discharge. The social justice framework works in this course of discharge was to ensure that the patient received quality care at home, as when admitted.

On the discharge day, the patient and caregivers were given a summary of the diagnosis, the illness, and the outcome. A registered nurse gave them discharge instructions, which they shall use to continue mitigating the illness. The caregivers and the patient provided the address and contact, which will aid follow-up. Also, they were given a follow-up schedule by the nurse.

References

Bilgili, B., Haliloglu, M., and Cinel, I., 2015. Sepsis and Acute Kidney Injury. Turkish Journal of Anesthesia and Reanimation, 42(6), pp.294-301.

Davis, A., Langmack, G., and Wood, S., 2017. RLO: Exploring The Sepsis Care Bundle. [online] Nottingham.ac.uk. Available at: <https://www.nottingham.ac.uk/nursing/sonet/rlos/placs/sepsis-care-bundle/sepsis-priorities.html> [Accessed 24 August 2020].

Gauer, R., 2016. Early Recognition and Management of Sepsis in Adults: The First Six Hours. Family Physician, 88(1), pp.44-53.

Kalil, A., 2019. Septic Shock: Practice Essentials, Background, Pathophysiology. [online] Emedicine.medscape.com. Available at: <https://emedicine.medscape.com/article/168402-overview> [Accessed 24 August 2020].

Seymour, C., and Rosengart, M., 2015. Septic Shock. JAMA, 314(7), p.708.

Smolowitz, J., Speakman, E., Wojnar, D., Whelan, E., Ulrich, S., Hayes, C., and Wood, L., 2015. Role of the registered nurse in primary health care: Meeting health care needs in the 21st century. Nursing Outlook, 63(2), pp.130-136.

Sproston, N., and Ashworth, J., 2018. Role of C-Reactive Protein at Sites of Inflammation and Infection. Frontiers in Immunology, 9.

Yolanda Smith, B., 2019. Roles Of A Nurse. [online] News-Medical.net. Available at: <https://www.news-medical.net/health/Roles-of-a-Nurse.aspx> [Accessed 24 August 2020].