SEPTIC SHOCK

Critical Care Case Study: Septic Shock Niki Hester 00531 !! O"# o$ Ca%pus

Su&%itted i$ partial 'ul'ill%e$t o' the re(uire%e$ts i$ the course N#)S !51: Critical Care Nursi$* Cli$ical Old "o%i$io$ #$i+ersity NO),O-K. /I)0INI1 ,all. 2011

SEPTIC SHOCK Critical Care Case Study: Septic Shock The purpose o' this case study is to allo3 the $ursi$* stude$t to i$te*rate k$o3led*e o'

the scie$ces a$d hu%a$ities. i$cludi$* $ursi$* research a$d theory to pla$. pro+ide a$d e+aluate care o' a selected patie$t duri$* critical care cli$ical rotatio$4 The paper 3ill discuss &ack*rou$d o$ the clie$t to i$clude past %edical a$d sur*ical history. reaso$ 'or hospitali5atio$ a$d ad%issio$ to I$te$si+e Care #$it4 The patie$ts6 %edical dia*$osis to i$clude cli$ical %a$i'estatio$s a$d pathophysiolo*y. alo$* 3ith prioriti5atio$ o' $ursi$* dia*$oses. outco%es. a$d holistic. %ultidiscipli$ary i$ter+e$tio$s. 3ill &e discussed as 3ell4 E+aluatio$ o' the e''ecti+e$ess o' care pro+ided to the patie$t 3ill also &e addressed a$d 3ill i$clude pro*ress to3ard outco%e achie+e%e$t a$d additio$al a$d7or alter$ati+e i$ter+e$tio$s 3ill &e pro+ided4 The patie$t selected 3as 84K4 a$ 2 year old Caucasia$ %ale 3ho prese$ted to Se$tara Careple9 E%er*e$cy "epart%e$t o$ Octo&er 2:. 2011 3ith co%plai$ts o' $ausea. +o%iti$* a$d a&do%i$al pai$ that started the day prior4 1ssess%e$t i$ the E%er*e$cy "epart%e$t $oted he had a lo3;*rade 'e+er o' 10043 de*rees ,ahre$heit. tachycardia 3ith a rate o' 1!2. tachyp$ea 3ith respiratio$s o' <3. i$itial &lood pressure o' 13<7=< 3hich dropped to <:752. a$d he 3as hypo9ic 3ith a$ o9y*e$ saturatio$ o' 2> o$ 15 - o' o9y*e$4 Patie$t has history o' rece$t hospitali5atio$. 1u*ust to Septe%&er 2011 'or a -aproscopic )i*ht Colecto%y 'or &e$i*$ ri*ht colo$ polyps4 His hospitali5atio$ 3as co%plicated 3ith de+elop%e$t o' &oth a$ i$tra&do%i$al a&scess a$d i$tracuta$eous 'istula4 He 3as treated a$d dischar*ed to a local $ursi$* ho%e 'or t3o 3eeks to 'i$ish his a$ti&iotic therapy o' i$tra+e$ous Ty*acil. Cipro. a$d "i'luca$4 The patie$ts past %edical history i$cludes "i+erticulosis o' the colo$. colo$ polyps. osteoporosis. de%e$tia. hyperte$sio$. thyroid disease. e$lar*ed prostate a$d *lauco%a4 ?;rays 3ere co%pleted upo$ curre$t E%er*e$cy )oo% +isit. a$d the patie$t 3as 'ou$d to ha+e a s%all

SEPTIC SHOCK

o&structio$ a$d le't lu$* aspiratio$ p$eu%o$ia4 ,urther e9a%i$atio$ re+ealed the patie$t 3as $ot a sur*ical ca$didate. so his 0astroe$terolo*y sur*eo$ re(uested the patie$t &e ad%itted to the I$te$si+e Care #$it 'or 'urther i$patie$t %a$a*e%e$t4 Medical Diagnosis ICU Admission and Pathophysiology of Diagnosis The patie$t 3as ad%itted to the I$te$si+e Care #$it 3ith a %edical dia*$osis o' Septic Shock4 ,or this particular patie$t. the s%all &o3el o&structio$ led to the aspiratio$ p$eu%o$ia a$d ulti%ately the de+elop%e$t o' Septic Shock4 Septic shock is de'i$ed as sepsis;i$duced shock 3ith %a$i'estatio$s o' hypote$sio$ a$d hypoper'usio$4 ,or this patie$t. his etiolo*y o' septic shock 3as the aspiratio$ p$eu%o$ia as a result o' his de+elop%e$t o' a s%all &o3el o&structio$ @SAOB4 Che$ %ediators 3ithi$ the &ody are acti+ated duri$* i$'la%%atory a$d i%%u$e respo$ses. patie$ts typically ha+e pro&le%s 3ith clotti$* as 3ell as distri&utio$ o' &lood 'lo3 to tissue a$d or*a$s resulti$* i$ alteratio$s o' %eta&olic state4 Hypo9e%ia occurs as a result o' i%&ala$ced o9y*e$ supply a$d de%a$d. leadi$* to cellular hypo9ia a$d death4 -actate le+els i$ the &lood 3ill rise as a result o' the shi't 'ro% aero&ic to a$aero&ic respiratio$ 3hich i$creases respiratory rate a$d decreases cardiac output4 Septic patie$ts i$itially prese$t 3ith )espiratory alkalosis. i$ 3hich they ha+e a hi*h pH. lo3 partial pressure o' o9y*e$ a$d car&o$ dio9ide @PaO2 D PaCO2B. a$d lo3 &icar&o$ate 3hich 'urther i$creases the patie$ts respiratory4 This process is o$e o' the &odies6 'eed&ack %echa$is%s4 O$ce the patie$t &eco%es 'ati*ued 'ro% their i$creased respiratory rate. their PaCO2 a$d pH i$crease se$di$* the% i$to )espiratory acidosis4 Hypoper'usio$ o' or*a$s like the kid$eys leads to 1cute )e$al ,ailure a$d is co%%o$ly see$ i$ patie$ts 3ith Septic Shock @#rde$. Stacy. D -ou*h. 2010B4

SEPTIC SHOCK Presenting Clinical Manifestations

#po$ assess%e$t. it 3as $oted that the patie$t 3as still septic &ecause his Heart )ate 3as *reater tha$ =0 &eats per %i$ute. he 3as tachyp$eic a$d his Chite Alood Cell cou$t 3as 1<45 K7u-4 His &lood a$d sputu% cultures 3ere positi+eE he 3as $oted to ha+e Fethicilli$;resista$t Staphylococcus aureus @F)S1B i$ his sputu%4 The patie$t has a history o' de%e$tia. a$d 3as $oted to ha+e a$ altered le+el o' co$scious$ess despite $ot recei+i$* a$y sedatio$4 The patie$t6s &lood *lucose le+el 3as 1!3 %*7dl. a$d his Sodiu% 3as 151 %%ol7- as a result o' recei+i$* i$tra+e$ous "e9trose 5> i$ NS4 That sa%e day a'ter rou$ds. the patie$t 3as s3itched to i$tra+e$ous "e9trose 5> i$ Cater4 The $e9t day. his *lucose 3as 120 %*7dl a$d his sodiu% 3as 1!3 %%ol7d-4 The hi*h sodiu% le+el i$ the patie$ts6 &lood 3as also a result o' the patie$ts 1cute )e$al ,ailure4 The i$crease i$ sodiu% rete$tio$ is also a result o' dehydratio$ a$d hyper+e$tilatio$4 Sodiu% is retai$ed &ecause the patie$ts or*a$s are &ei$* hypoper'used there'ore. the &ody is holdi$* o$to sodiu% i$ order to retai$ 'luid to correct hypo+ole%ia @#rde$. et al4. 2010B4 ,urther assess%e$t a$d re+ie3 o' the patie$ts %edical record sho3ed the patie$ts6 he%o*lo&i$ a$d he%atocrit 3ere 1042 *7dl a$d 3141>. i$dicati$* he 3as a$e%ic as a result o' the hypo9ia4 "ue to the patie$ts6 s%all &o3el o&structio$. his Percuta$eous E$doscopic 0astrosto%y @PE0B tu&e 3as drai$i$* copious a%ou$ts o' *ree$ drai$a*e. rou*hly 30;50 %illiliters per hour4 The patie$t 3as also $oted to ha+e a Alood #rea Nitro*e$ le+el o' 2< %*7dl i$dicati$* &oth e9cessi+e protei$ &reakdo3$ a$d co$'ir%i$* the dia*$osis o' 1cute )e$al ,ailure4 1s a result o' the Sepsis. 1cute )e$al ,ailure a$d )espiratory "istress. the patie$t de+eloped lactic acidosis4 The patie$ts6 lactic acid le+el 3as 20 %*7dl4 The patie$ts 1rterial Alood 0as results 3ere as

SEPTIC SHOCK 'ollo3s: pH <45. PaCO2 o' %%H*. PaO2 o' 2 %%H*. Aicar&o$ate o' 234! %%ol7-. a$d a$ arterial o9y*e$ saturatio$ o' =<> i$dicati$* the patie$t i$ curre$tly i$ respiratory alkalosis4 Nursing Diagnosis Nursing Diagnoses and Prioritization Che$ prioriti5i$* $ursi$* dia*$oses &ased o$ &ody syste%s. this patie$t6s pri%ary

pro&le% is )espiratory4 1 )espiratory $ursi$* dia*$osis rele+a$t 'or this patie$t is I%paired 0as E9cha$*e related to altered o9y*e$ supply. altered &lood 'lo3. a$d altered o9y*e$;carryi$* capacity o' &lood4 Supporti$* o&Gecti+e a$d su&Gecti+e data 'or the priority dia*$osis i$cludes: tachyp$ea 3ith a respiratory rate o' 30 &reaths per %i$ute. coarse &reath sou$ds &ilaterally a$d i$ the &ases. 1rterial Alood 0as results i$dicated respiratory alkalosis. lo3 he%o*lo&i$. he%atocrit. a$d al&u%i$4 1$other respiratory pro&le% 'or %y patie$t is i$'ectio$4 The patie$ts6 i$'ectio$ is related to the patie$ts6 s%all &o3el o&structio$ 3hich led to his aspiratio$ p$eu%o$ia4 Supporti$* e+ide$ce i$cludes a Chite Alood Cell cou$t o' 1<45 K7u- a$d positi+e sputu% cultures 'or F)S1 a$d yeast @0ula$ick D Fyers. 200<B4 The seco$d &ody syste% &ased o$ prioriti5atio$ is the Ner+ous syste%4 The selected $ursi$* dia*$osis is 1ltered Se$sory Perceptio$: tactile related to dia*$osis o' lactic acidosis. cere&ral hypo9ia a$d altered le+el o' co$scious$ess as e+ide$ced &y hyper$atre%ia. 0las*o3 Co%a Scale score o' :. a$d %i$i%al to a&se$t respo$se to tactile pai$'ul a$d $o9ious sti%uli4 ,or the third $ursi$* dia*$osis. a co%&i$atio$ o' t3o &ody syste%s is appropriate4 The co%&i$ed &ody syste%s are Fuscular a$d Skeletal4 1$ appropriate Fusculoskeletal $ursi$* dia*$osis is I%paired Physical Fo&ility related to the patie$ts6 history o' osteoporosis. curre$t hi*h 'all risk status. &ilateral upper e9tre%ity restrai$ts 'or sa'ety due to %echa$ical +e$tilatio$ a$d altered le+el o' co$scious$ess as e+ide$ced &y patie$t &ei$* co%pletely i%%o&ile.

SEPTIC SHOCK de%o$strati$* %i$i%al to a&se$t spo$ta$eous e9tre%ity %o+e%e$t. 0las*o3 Co%a Scale score o' :. a$d i$a&ility to repositio$ sel' i$depe$de$tly @0ula$ick et al4. 200<B4 The 'ourth $ursi$* dia*$osis is I%paired Ski$ I$te*rity related to patie$ts6 a*e. i%%o&ility. poor $utritio$ a$d circulatio$. &ilateral upper e9tre%ity restrai$ts. history o' sacral pressure ulcers. le't a&do%i$al PE0 tu&e. a$d Ce$tral /e$ous -i$e as e+ide$ced &y al&u%i$ le+el o' 243 *7dl. curre$t Sta*e II pressure sore o$ coccy9. ski$ tear o$ le't k$ee a$d poor ski$

tur*or4 1 'i'th $ursi$* dia*$osis is 1ltered ,a%ily Processes: I$e''ecti+e ,a%ily Copi$* related to se+ere ill$ess o' 'a%ily %e%&er. cha$*es i$ 'a%ily roles. 'i$a$cial crisis related to prolo$*ed I$te$si+e Care #$it hospitali5atio$ a$d co$'lict &et3ee$ 'a%ily %e%&ers as e+ide$ced &y the patie$ts6 3i'e a$d so$ disa*reei$* o$ care 'or patie$t. social isolatio$ o' 3i'e. 3i'e taki$* o$ %ale role at ho%e. a$d e%otio$al i$sta&ility o' i%%ediate 'a%ily %e%&ers as a result o' *rie' a$d a$9iety4 1$ additio$al $ursi$* dia*$osis is I%&ala$ced Nutritio$: -ess Tha$ Aody )e(uire%e$ts related to s%all &o3el o&structio$. $othi$* &y %outh *reater tha$ ! days. %al$utritio$. dehydratio$. i$creased %eta&olic $eeds caused &y %edical dia*$osis as e+ide$ced &y 3ei*ht loss o' appro9i%ately three a$d a hal' kilo*ra%s i$ ! days. al&u%i$ le+el o' 243 *7dl. a$e%ia. PE0 tu&e drai$i$* copious a%ou$ts o' *ree$ drai$a*e. delayed sacral 3ou$d heali$* a$d 2!;hour i$take less tha$ output @0ula$ick et al4. 200<B4 Che$ deter%i$i$* prioriti5atio$ o' $ursi$* dia*$oses. it 3as appare$t that the patie$ts6 respiratory status 3as $u%&er o$e priority4 )atio$ale 'or this prioriti5atio$ is directly related to the patie$ts $eed 'or %echa$ical +e$tilatio$. curre$t state o' respiratory alkalosis. aspiratio$ p$eu%o$ia caused &y his s%all &o3el o&structio$ 3hich led to i$'ectio$ a$d ulti%ately the patie$ts6 de+elop%e$t o' Septic Shock4 The seco$d $ursi$* dia*$osis 3as selected as a priority &ecause the patie$ts6 $eurolo*ical 'u$ctio$ directly i%pacts other &ody syste%s i$cludi$*

SEPTIC SHOCK Fusculoskeletal a$d I$te*u%e$tary4 The third a$d 'ourth $ursi$* dia*$oses 3ere prioriti5ed &ased o$ the 'act that the patie$ts6 i%%o&ility 3as a %aGor co$tri&utor to the patie$ts i%paired ski$ i$te*rity4 The 'i'th $ursi$* dia*$osis 3as selected &ecause the patie$ts6 curre$t co$ditio$ a$d prolo$*ed hospitali5atio$ i$ the I$te$si+e Care #$it has tre%e$dously a''ected his 'a%ily especially his 3i'e4 The $ursi$* dia*$osis o' 1ltered ,a%ily Processes: I$e''ecti+e ,a%ily Copi$* 3as selected &ecause it i$corporated the 'a%ily i$to the patie$ts care a$d 3as a pri%e e9a%ple o' ho3 the patie$ts6 curre$t hospitali5atio$ had $e*ati+e e''ects o$ each i$di+idual 'a%ily %e%&ers a$d their a&ility to 'u$ctio$ i$ their daily li+es4 The reaso$ the patie$ts *astroi$testi$al pro&le% 3as $ot selected as a priority $ursi$* dia*$osis 3as &ecause the

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patie$t6s %edical tea% decided to %ai$tai$ the patie$t o$ &o3el rest &ecause o' his de+elop%e$t o' a s%all &o3el o&structio$ 3hich resulted i$ aspiratio$ p$eu%o$ia4 The patie$t 3as curre$tly $ot recei+i$* a$d 'or% o' $utritio$. &ut o$ day t3o o' cli$ical duri$* rou$ds. there 3as discussio$ a&out i$troduci$* trickle 'eeds to deter%i$e the patie$ts6 pro*ress4 Nursi$* care o' the patie$t 3as to 'ollo3 %edical orders a$d co$ti$ue to %o$itor the patie$ts PE0 tu&e 'or drai$a*e $oti$* a%ou$t a$d color4 O$ce 'eedi$*s are rei$troduced. the patie$ts6 0astroi$testi$al 'u$ctio$ 3ould &e o' hi*her i%porta$ce &ecause o' i$creased risk o' 'uture aspiratio$. there'ore it 3ould %o+e to a hi*her priority status4 )e'er to 1ppe$di9 1 'or co%plete co$cept %ap details4 Nursing Theory and Interrelatedness to Nursing Diagnoses 1&dellah6s theory o' Patie$t;Ce$tered 1pproaches 3as utili5ed 3he$ prioriti5i$* the selected $ursi$* dia*$oses4 1&dellah6s typolo*y Hhelps the $urse to or*a$i5e the ad%i$istratio$ o' care a$d pro+ides a scie$ti'ic &ase 'or %aki$* cli$ical decisio$sI @8oh$so$ D Ce&&er. 2010. p4 131B4 Fa$y o' 1&dellah6s ide$ti'ied $ursi$* pro&le%s related to the patie$ts $ursi$* pla$ o' care4 ,or e9a%ple. o$e o' her pro&le%s states to reco*$i5e the physiolo*ic respo$se o' the &ody

SEPTIC SHOCK to ill$ess4 This particular *oal supports %y pri%ary respiratory $ursi$* dia*$osis &ecause the patie$t de+eloped respiratory alkalosis as a result o' his Septic Shock4 The &ody i$itially reacts to hypo9ia &y i$creasi$* respiratory rate to try a$d distri&ute o9y*e$ to the tissues4 Si$ce o9y*e$ is $ot &ei$* deli+ered to the &ody ade(uately. the patie$t hyper+e$tilates a$d pro'ou$d respiratory alkalosis de+elops @8oh$so$ et al4. 2010B4 1 *oal to support the prioriti5atio$ o' the Neurolo*ical $ursi$* dia*$osis is to 'acilitate %ai$te$a$ce o' se$sory 'u$ctio$4 This *oal 3as selected &ecause si$ce the patie$t had altered %e$tal status a$d 3as i$ a hea+ily sedated state. proper assess%e$t o' se$sory 'u$ctio$ 3as a +ery i%porta$t aspect o' the patie$ts6 pla$ o' care4 1$other i%porta$t *oal utili5ed 3he$ prioriti5i$* $ursi$* dia*$oses 3as to %ai$tai$ *ood hy*ie$e a$d physical co%'ort4 Physical co%'ort e+e$ i$ a sedated patie$t is key to pre+e$ti$* pressure sores a$d ulceratio$4 -astly. 'ro% a psychosocial sta$dpoi$t. it 3as a priority to ide$ti'y a$d accept the i$terrelated$ess o' e%otio$s a$d ill$ess4 Si$ce there 3as discussio$ &et3ee$ the patie$ts 3i'e. so$ a$d doctor re*ardi$* pla$ o' care a$d poor pro*$osis. it 3as +ery di''icult 'or the 'a%ily to deal 3ith the $e3s a$d there'ore it had a direct i%pact o$ their e%otio$al status @8oh$so$ et al4. 2010B4 Expected utcomes

,or the $ursi$* dia*$osis o' I%paired 0as E9cha$*e. the e9pected outco%e 3as the patie$t 3ill %ai$tai$ opti%al *as e9cha$*e throu*hout shi't as e+ide$ced &y arterial &lood *ases 3ithi$ the patie$ts usual ra$*e. $o 'urther reductio$ i$ %e$tal status. $o si*$s o' respiratory distress. $o cha$*es i$ +ital si*$s to i$clude 3orse$i$* tachycardia or hyperte$sio$. %ai$te$a$ce o' pulse o9i%etry *reater tha$ =2 perce$t a$d he%o*lo&i$ a$d he%atocrit 3ithi$ $or%al ra$*e 'or hospital policy4 ,or the $ursi$* dia*$osis o' 1ltered Se$sory Perceptio$: tactile. the e9pected outco%e 3as 'or the patie$t to re%ai$ 'ree 'ro% physical har% duri$* shi't a$d

SEPTIC SHOCK

throu*hout hospitali5atio$ as e+ide$ced &y $o decli$e i$ %e$tal status. i%pro+e%e$t i$ alert$ess. 0las*o3 Co%a Scale score *reater tha$ &y seco$d cli$ical day. a$d i%pro+e%e$t i$ respo$se

to tactile a$d $o9ious sti%uli4 The e9pected outco%es 3ere de+eloped &ased o$ $ursi$* dia*$osis prioriti5atio$ a$d are %easura&le a$d rele+a$t to the patie$ts6 curre$t health status @0ula$ick et al4. 200<B4 Nursing Inter!entions Nursing Diagnosis " # The $u%&er o$e priority i$ter+e$tio$ 'or $ursi$* dia*$osis o$e is to colla&orate 3ith respiratory therapy a$d physicia$s to %ai$tai$ the patie$t o$ the prescri&ed +e$tilator support a$d to assist 3ith 3ea$i$* process as $eeded4 Sta$dard o' Practice /II: )esearch 3as utili5ed 3he$ deter%i$i$* care o' patie$t o$ %echa$ical +e$tilatio$4 1 k$o3$ co%plicatio$ o' %echa$ical +e$tilatio$ is /e$tilator 1ssociated P$eu%o$ia4 1$ i$depe$de$t $ursi$* i$ter+e$tio$ 3ould &e to pro+ide oral care e+ery 'our hours a$d as $eeded to pre+e$t &uildup o' secretio$s4 1 depe$de$t i$ter+e$tio$ is the physicia$s6 order o' chlorhe9idi$e oral solutio$ t3ice daily4 1 research study co$ducted &y Fu$ro. 0rap. 8o$es. FcClish a$d Sessler @200=B. e9a%i$ed %echa$ically +e$tilated patie$ts a$d the e''ects o' tooth&rushi$*. use o' chlorhe9idi$e oral ri$se a$d co%&i$atio$ o' oral care tech$i(ues o$ the de+elop%e$t o' +e$tilator;associated p$eu%o$ia4 The study i$cluded a co$trol *roup. a$d althou*h so%e o' their data supported $o si*$i'ica$t decrease i$ de+elop%e$t o' +e$tilator;associated p$eu%o$ia. a s%aller *roup o' patie$ts 3hose Cli$ical Pul%o$ary I$'ectio$ Score 3as *reater tha$ or e(ual to si9 o$ +e$tilator day o$e had si*$i'ica$tly 'e3er patie$ts de+elop +e$tilator;associated p$eu%o$ia &y day three4 Si$ce +e$tilator;associated p$eu%o$ia has detri%e$tal e''ects i$cludi$* i$creased healthcare costs a$d i$creased %or&idity a$d %ortality. this i$ter+e$tio$ has pro+e$ that e+e$ thou*h oral

SEPTIC SHOCK

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care does$6t si*$i'ica$tly reduce your risk o' p$eu%o$ia. e+ery e''ort to pre+e$t i$'ectio$ helps @Fu$ro et al4. 200=B4 1$other research study co$ducted &y ,eider. Fitchell. a$d Arid*es @2010B. e9a%i$ed oral care practices per'or%ed &y critical care $urses o$ orally i$tu&ated patie$ts4 The study co$cluded that the %aGority o' the $urses reported per'or%i$* oral care e+ery t3o hours a$d the $u%&er o$e procedure 3as use o' 'oa% s3a&4 Se+e$ty;t3o perce$t o' the $urses i$dicated their 'acility had a$ oral care policy 'or orally i$tu&ated patie$ts4 1ppro9i%ately !< perce$t o' the $urses reported oral care as a hi*h priority. a$d those 3ith %ore $ursi$* e9perie$ce a$d educatio$ 3ere li$ked to pro+idi$* patie$ts 3ith &etter (uality o' care i$cludi$* proper assess%e$t a$d use o' su$ctio$i$* 3he$ $eeded @,eider et al4. 2010B4 1$ i$depe$de$t $ursi$* i$ter+e$tio$ is co$ti$ued assess%e$t a$d %o$itori$* o' lu$* sou$ds. +ital si*$s a$d pulse o9i%etry4 Fo$itori$* o' la&oratory +alues especially he%o*lo&i$ a$d he%atocrit. arterial &lood *ases. lactic acid a$d a%%o$ia is a$other depe$de$t i$ter+e$tio$ ordered &y the physicia$ a$d i%ple%e$ted &y the $urse4 Fo$itori$* lu$* status a$d la&oratory +alues allo3s the e$tire %edical tea% to track the patie$ts6 pro*ress a$d assists the% i$ deter%i$i$* pla$ o' care4 1$other i$ter+e$tio$ 3as de+eloped usi$* sta$dard o' practice III: Educatio$4 The i$ter+e$tio$ is the stude$t 3ill educate the patie$ts6 'a%ily re*ardi$* the i%porta$ce o' 3eari$* Perso$al Protecti+e E(uip%e$t &ecause o' the his curre$t respiratory i$'ectio$4 Pro+idi$* educatio$ related to the patie$ts6 %edical dia*$osis as 3ell as 3ays to pre+e$t spread o' i$'ectio$ is +ital to &oth the patie$ts6 health a$d the health o' the surrou$di$* patie$ts a$d +isitors4 1 depe$de$t i$ter+e$tio$ related to the patie$ts6 respiratory i$'ectio$ is the $urse 3ill ad%i$ister i$tra+e$ous a$ti&iotics i$cludi$* Cipro'lo9aci$ !00 %* e+ery 12 hours.

SEPTIC SHOCK /a$co%yci$ 1000 %* o$e ti%e daily. a$d "ori&a9 500 %* e+ery ei*ht hours as prescri&ed &y physicia$ @0ula$ick et al4. 200<B4 Nursing Diagnosis " $ The priority i$ter+e$tio$ 'or the patie$t re*ardi$* his $eurolo*ical status is to per'or%

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a$d report the 0las*o3 Co%a Scale score4 This is a$ i$depe$de$t $ursi$* i$ter+e$tio$ that the $urse ca$ per'or% (uickly to assess the patie$ts6 le+el o' co$scious$ess4 )e+ie3 o' literature supported the use o' the 0las*o3 Co%a Scale as a %ea$s o' assessi$* le+el o' co$scious$ess. a$d $urses ha+e reported it to &e a (uick. o&Gecti+e a$d easy tool 3he$ reporti$* $eurolo*ical status4 The scale %easures three areas i$cludi$* eye ope$i$*. +er&al a$d %otor respo$se4 )esearch has sho3$ success 3ith use o' the scale as lo$* as it is &ei$* used i$ the sa%e %a$$er &y all healthcare pro'essio$als so i$terpretatio$ scori$* is &ased o$ *roup u$dersta$di$* o' each o&ser+atio$ cate*ory4 I$ additio$ to per'or%i$* the 0las*o3 Co%a Scale. other i$depe$de$t i$ter+e$tio$s i$clude recordi$* the patie$ts6 +ital si*$s a$d reporti$* +alues out o' the $or%al. a$d assessi$* patie$ts6 pupillary respo$se as a$ additio$al part o' the $eurolo*ical assess%e$t4 )atio$ale 'or per'or%i$* $eurolo*ical checks a$d assess%e$t o' +ital si*$s is that these %easures e$sure cha$*es i$ patie$t status are $oticed i$ a ti%ely %a$$er so appropriate actio$ ca$ &e take$ &y %edical sta''4 1 $urse6s a&ility to use cli$ical Gud*%e$t a$d take actio$ 3he$ the patie$t sho3s cha$*es i$ $eurolo*ical status are +ital @"a3es. -loyd. D "urha%. 200<E 0ula$ick et al4. 200<B4 To address the patie$ts6 tactile se$sory de'icit. it is i%porta$t to also i$corporate &oth %usculoskeletal a$d ski$ i$te*rity i$ter+e$tio$s &ecause the patie$t6s lack o' se$satio$ a$d a&se$t respo$se to &oth pai$'ul a$d $o9ious sti%uli puts hi% at risk 'or 'urther ski$ &reakdo3$4 O$e i$depe$de$t $ursi$* i$ter+e$tio$ 1 research study co$ducted &y Krap'l a$d 0ray @200 B

SEPTIC SHOCK

12

e9a%i$ed pre+e$ti+e strate*ies i$cludi$* repositio$i$* to deter%i$e i' it helps %i$i%i5e pressure ulcer de+elop%e$t4 The study co$cluded that repositio$i$* the patie$t e+ery 'our hours 3as Gust as e''ecti+e as repositio$i$* the% e+ery t3o hours4 I%plicatio$ to $ursi$* practice de%o$strates that repositio$* patie$ts re*ularly aids i$ the pre+e$tio$ o' pressure sores a$d ski$ &reakdo3$4 Colla&orati+e i$ter+e$tio$s i$clude physicia$s order 'or a head Co%puted Topo*raphy ca$ to deter%i$e i' there 3ere a$y structural da%a*es4 1$other i$depe$de$t i$ter+e$tio$ is to pro+ide the patie$ts6 'a%ily 3ith rei$'orced educatio$ related to possi&le causes o' the patie$ts6 sedatio$; like state to i$clude the septic shock 3hich caused hypo9e%ia a$d hypoper'usio$ o' or*a$s @Krap'l et al4. 200 B4 Sta$dard o' Care I: 1ssess%e$t 3as utili5ed 3he$ de+elopi$* a$ i$depe$de$t i$ter+e$tio$4 The i$ter+e$tio$ i$cluded re*ular assess%e$t o' ski$ i$te*rity a$d a&ility to respo$d to tactile sti%uli $oti'yi$* physicia$ o' cha$*es i$ patie$t status &ased o$ $ursi$* Gud*%e$t4 Per'or%i$* 're(ue$t $eurolo*ical checks a$d ski$ assess%e$ts ca$ help pre+e$t 'urther co%plicatio$s 'ro% occurri$*4 Culture The patie$ts6 'a%ily culture positi+ely i%pacted the care that 3as pro+ided to the%4 "iscussio$ o' 'a%ily +alues a$d &elie's especially a&out %edical care 3as i%porta$t to the patie$ts6 3i'e4 She e9pressed that she u$derstood the se+erity o' her hus&a$d6s co$ditio$. &ut she k$e3 he 3ould $ot 3a$t to *i+e up4 There 3ere a lot o' co$cer$s that the patie$ts 'a%ily had i$cludi$* *rie' a$d 'a%ily dy$a%ics4 The so$ a$d %other are the o$ly t3o close to the hospital. a$d the 3i'e is ha+i$* a di''icult ti%e $ot ha+i$* all o' her childre$ 3ith her duri$* this hard ti%e4 The patie$ts6 3i'e co$+eyed to the stude$t $urse that she al3ays prays at ho%e 3ith her hus&a$d. so she asked i' I 3ould do it 3ith her at the hospital4 I$corporati$* cultural practices i$to the care o' the patie$ts helps you to &uild a therapeutic relatio$ship4 Other cultural

SEPTIC SHOCK co$sideratio$s i$cludes pro+idi$* the 3i'e a$d so$ 3ith educatio$ a$d updates pertai$i$* to

13

patie$t status &ecause si$ce they ha+e such a close 'a%ily. co%%u$icatio$ 3ith &oth dista$t a$d i%%ediate 'a%ily is i%porta$t to the%4 E!aluation of Plan of Care utcome E!aluation and Alternati!es to Plan of Care Outco%e e+aluatio$ 'or $ursi$* dia*$osis $u%&er o$e. is that the e9pected outco%e 3as partially %et4 The patie$ts6 arterial &lood *ases 3ere out o' the $or%al ra$*e de%o$strati$* respiratory alkalosis4 -a&oratory +alues 3ere: pH <4!<. PaO2 :5. PaCO2 2=42. &icar&o$ate 214! a$d arterial o9y*e$ saturatio$ o' =! perce$t4 The patie$t did $ot e9hi&it a$d 'urther decli$e i$ $eurolo*ical state. a$d his 0las*o3 Co%a Scale score re%ai$ed at a :4 The patie$t also did $ot e9perie$ce a$y 3orse$i$* o' +ital si*$s4 Heart rate 3as lo3ered 'ro% day o$e to day t3o 3ith 'irst day &eats per %i$ute ra$*e i$ the 1006s to 1106s a$d day t3o &et3ee$ 06s a$d =06s4 The patie$ts6 he%o*lo&i$ a$d he%atocrit re%ai$ed 'ro% 'or &oth day o$e a$d day t3o 3ith day t3o +alues &ei$* 1042 a$d 3141. 3hich is lo3er tha$ the $or%al ra$*e per the hospital policy4 Outco%es e+aluatio$ 'or $ursi$* dia*$osis $u%&er t3o. is that the e9pected outco%e 3as partially %et4 The patie$t did de%o$strate %i$i%al respo$se to pai$'ul sti%uli &y sli*htly 3ithdra3i$* his ha$d 3he$ the doctor applied pressure o$ the patie$ts 'i$*er $ail4 The patie$t ho3e+er. did $ot e9perie$ce a$y i%pro+e%e$t i$ alert$ess duri$* %y t3o day shi't4 The patie$t did e9hi&it i$+olu$tary upper a$d lo3er e9tre%ity %o+e%e$ts. &ut his 0las*o3 Co%a Scale score re%ai$ed at a : 'or &oth days o' cli$ical e9perie$ce4 O+erall the patie$ts6 pro*ress 3as %i$i%al o+er t3o days &ut the patie$t re%ai$ed i$ sta&le co$ditio$ duri$* the t3o days o' cli$ical e9perie$ce4

SEPTIC SHOCK 1$ additio$al re+ie3 o' literature 'or pressure ulcer pre+e$tio$ $ursi$* i$ter+e$tio$s de%o$strated that there are %a$y additio$al tech$i(ues you ca$ use to e$sure your patie$t

1!

does$6t de+elop a pressure ulcer4 Other i$ter+e$tio$s i$clude. %ai$tai$i$* ade(uate $utritio$ a$d hydratio$. %i$i%i5e a$d %a$a*e %oisture. %i$i%i5e 'rictio$ a$d shear. educate the patie$ts6 'a%ily o$ the ratio$ale 'or repositio$i$* a$d thorou*h ski$ assess%e$t each shi't4 1dditio$al depe$de$t i$ter+e$tio$s 3ould &e 'urther $eurolo*ical studies to i$clude additio$al testi$* o' &rai$ 'u$ctio$. additio$al a$alysis to deter%i$e i' a$y cha$*es 'ro% pre+ious heart CT @Ala$ey. 2010B4 Conclusion This case study assi*$%e$t pro+ided the $ursi$* stude$t 3ith the opportu$ity to 'ully research their selected patie$t. a$d use the i$'or%atio$ they lear$ed to de+elop a$d i%ple%e$t a pla$ o' care &ased o$ their prioriti5atio$ o' $ursi$* dia*$oses4 E9pected outco%es a$d $ursi$* i$ter+e$tio$s 3ere de+eloped a$d 'ollo3ed throu*h 3ith. a$d e+aluatio$ o' the e9pected outco%e 3as per'or%ed to deter%i$e i' patie$t 3as %eeti$* the a$ticipated *oals4 The selected patie$t 3as a$ 2 year old Caucasia$ %ale 3ho 3as dia*$osed 3ith a s%all &o3el o&structio$ 3hich led to aspiratio$ p$eu%o$ia a$d septic shock4 Throu*h this case study I 3as a&le to lear$ a lot a&out septic shock a$d its pathophysiolo*y a$d its i$terrelated$ess o' &ody syste%s &ecause %ultiple or*a$s are a''ected4 I also *ai$ed the e9perie$ce o' cari$* 'or a critically ill patie$t a$d 3as a&le to see the psycholo*ical a$d e%otio$al e''ects that it has o$ 'a%ily a$d 'rie$ds4

SEPTIC SHOCK %eferences Ala$ey. C4 "4 @2010B4 Taki$* steps to pre+e$t pressure ulcers4 Nursi$* 2010. !!;!<4 )etrie+ed ,ro%

15

http:77Gour$als4l334co%7$ursi$*7,ullte9t720107030007Taki$*JstepsJtoJpre+e$tJpressureJ ulcers41:4asp94 "a3es. E4. -loyd. H4. D "urha% -4 @200<B4 Fo$itori$* a$d recordi$* patie$ts6 $eurolo*ical o&ser+atio$s4 Nursing Standard, 22@10B. !0;!54 )etrie+ed 'ro% http:773334%pd*p4co%4au7'iles7docs7laos>2520reco%%e$datio$s7%o$itori$*>2520a$d >2520recordi$*>2520patie$ts>2520$eurolo*ical>2520o&ser+atio$s4pd' ,eider. -4 -4. Fitchell. P4. D Arid*es. E4 @2010B4 Oral care practices 'or orally i$tu&ated critically ill adults4 American Journal of Critical Care, 19. 1<5;1 34 doi: 104!03<7aGcc2010 1: Hod*so$. A4 A4. Ki5ior. )4 84. @2011B4 Nursing Drug Handbook4 St4 -ouis. FO: Sau$ders4 8oh$so$. A4 F4. D Ce&&er. P4 A4 @200=B4 An introduction to theory and reasoning in nursing @3rd ed4B4 Philadelphia. P1: -ippi$cott Cillia%s D Cilki$s4 Krap'l. -4 14. D 0ray. F4 @200 B4 "oes re*ular repositio$i$* pre+e$t pressure ulcersK Journal of ound !stomy and Continence Nursing, "#. 5<1;5<<4 )etrie+ed 'ro% http:773334$ursi$*ce$ter4co%7li&rary7static4aspKpa*eidL !<=0< Fu$ro. C4 -4. 0rap. F4 84. 8o$es. "4 84. FcClish. "4 K4. D Sessler. C4 N4 @200=B4 Chlorhe9idi$e. tooth&rushi$*. a$d pre+e$ti$* +e$tilator;associated p$eu%o$ia i$ critically ill adults4 American Journal of Critical Care, 1$. !2 ;!3<4 doi: 104!03<7aGcc200=<=2

SEPTIC SHOCK %eferences Sta$dards o' acute a$d critical care $ursi$* practice4 @2011B4 American Association of Critical% Care Nurses4 )etrie+ed 'ro%

1:

http:773334aac$4or*7C"7Practice7Co$te$t7sta$dards4'or4acute4a$d4cc$ursi$*4practice4pc %sK%e$uLPractice #rde$. -4 "4. Stacy. K4 F4. D -ou*h. F4 E4 @2010B4 Critical Care Nursing Diagnosis and &anagement4 St4 -ouis. FO: Fos&y4

SEPTIC SHOCK Appendix A Concept Map Nutrition / Elimination: GI

Nutritio$ co$sult H9 di+erticulitis H9 -ap )i*ht Colecto%y @sepB; H9 &e$i*$ colo$ polyps NPO 7 PE0 tu&e -ICS; le't "ry oral %ucosa; %outh care (!h I/, M "5CN <5 %l7hr 56 I D 131 l&s 1&do%i$al diste$sio$ PE0 tu&e copious a%t *ree$ drai$a*e @30;50%l7hrB output A0-; 1!3@HB ; 120 @HB 1$e%ia @H*& 1042E Hct 3141B 1l&u%i$ 243 @-B 2! hr IDO M 13<571500 A#N 2! @HB Pepcid M Stress #lcer Prophyla9is. dehydratio$

1<

Musculoskeletal / Immobility
PT7OT co$sult H9 Osteoporosis Hi*h ,all )isk I%%o&ile ,rail M 13 l&s -ethar*ic )estrai$ed 'or sa'ety Hepari$ "/T Prophyla9is Spo$ta$eous e9tre%ity %o+e%e$t

Neuro
No respo$se to +er&al sti%uli o$ly respo$ds to pai$'ul sti%uli H9 de%e$tia -ethar*icE o&tu$ded 0CS: : Hi*h ,all )isk -actic 1cidosis Na M 151 @HB Spo$ta$eous e9t4 %o+e%e$t

82 YO WM &eptic &hoc' secondary to aspiration pneumonia as a result of &( A%)* +actic acidosis PM,- "i+erticulosis;colo$. polyps. de%e$tia. hyperte$sio$. *lauco%a. osteoporosis Family Process / Grieving
,a%ily a$ticipatory *rie' Ci'e. 2 adult childre$ @1 i$ 0er%a$yB I$di''ere$ces i$ 'a%ily opi$io$ re*ardi$* li'e support %easures @"N)7"NIB Pt $ot a&le to u$der*o sur*ery I%%ediate ,a%ily 'ro% a$other state

Cardiovascular
Si$us tachycardia ; Tele H9 a$terior FI H) M 112 @tachycardicB AP M 13:7 0 ,ati*ueE lethar*ic I/, M "5CN <5 %l7hr C/- )i*ht su&cla+ia$ HDH M 104273141 @-B Plt 1:! @-B

Fluid and !ytes

I/, M "5CN <5%l7hr I D O 1st day L 1125732:0 IDO 2$d day L 13<571500 Na M 151 @HB ; 1!3@HB A#N M 2< @HB O 2!@HB Electrolyte )eplace%e$t Protocol Cl M 11= @HB O 11!@HB "ehydratio$

Skin Integrity
I%%o&ility )estrai$ts A#E H9 pressure ulcer7deci&iti o$ sacru% PE0 tu&e 1l&u%i$ M 243 @-B Sta*e 2 pressure sore o$ coccy9 O co+ered 3K %epile9 ds* Sca& o$ le't k$ee O co+ered 3K Fepile9

Elimination "G#$
1%%o$ia @10730B 2:H9 1), ,oley M drai$i$* yello3 uri$e "ehydratio$ 2!h I D O M 13<571500 A#N M 2< @HB Na M 151 @HB Cl M 11= @HB I/, "5CN <5 %l7hr A0- M 120 @HB Cr 04< @-B

Res iratory
CAC M 1<45 @HB 1spiratio$ P$eu%o$ia I$tu&ated D %echa$ically +e$tilated O $ot sedated &7c lethar*ic !0> ,iO2E PEEP P5E SpO2 M =3> P)N )espiratory t9 'or 3hee5i$*; 1l&uterol 7 1tro+e$t )) M 30 &reaths per %i$ @Tachyp$eicB Coarse &reath sou$ds HDH 104273141 @-B )espiratory alkalosis: 1st day 1A06s: pH M <45 @HBE PaCO2 M 2= @-BE PaO2 M 2E HCO3 M 234!E O2 sat L =<> 2nd day ABGs: pH: 7.47 (H); PaO2: 65 (L); O2 sat: 94% (L); PaCO2: 2=42 @-BE HCO3: 214! @-B Cipro. /a$co%yci$. "ori&e9 Sputu% culture: P yeast D F)S1

SEPTIC SHOCK The ,onor PledgeHI pled*e to support the Ho$or Syste% o' Old "o%i$io$ #$i+ersity4 I 3ill re'rai$ 'ro% a$y 'or% o' acade%ic disho$esty or deceptio$. such as cheati$* or pla*iaris%4 I a% a3are that as a %e%&er o' the acade%ic co%%u$ity it is %y respo$si&ility to tur$ i$ all suspected +iolators o' the Ho$or Code4 I 3ill report to heari$* i' su%%o$ed4I Electro$ically si*$ed &y: Niki 84 Hester

SEPTIC SHOCK

1=

NU%& ./# Client Case &tudy 0rading Criteria Stude$t: Ni'i ,ester 0rading Criteria
Introduction Pt4 O+er+ie3 Scope o' paper Medical Diagnosis "9 'or IC# ad%4 Patho )elated S7S Nursing Diagnosis 5 N1N"1 @1P psych7socB Priority 3ith theorist support utcomes for top $ ND2 1ppropriate 'or N"? 1ttai$a&le 3ithi$ ti%e'ra%e Inter!entions for top $ ND2 I$ter+e$tio$s 3ith ratio$ale SOP 7Cli$ical Path Patie$t7'a%ily teachi$* Critical Thi$ki$* Cultural Co$sideratio$s E!aluation Pro*ress to3ard outco%es 1dditio$al7alter$ati+e pla$ Conclusion )e+ie3 o' lear$i$*

Score: JJJJJJJJJJ Points

2 1 2 ! ! 5 10 "# "$ 245 245 245 245 "# "$ : : 2 2 2 2 2 2 3 "# "$ 5 5 1 1

)aculty Comments

Points A1arded

SEPTIC SHOCK

20

0rading Criteria
&ources 5P sources 3P primary nursing research Study results re+ie3ed7applied Study poorly re+ie3ed7applied )esearch o%itted APA )ormat @Co+er pa*e. headi$*s. %ar*i$s. type si5eB ,or%at co$'or%s to 1P1 ,or%at ,or%at i$cludes 1;3 1P1 errors ,or%at i$cludes !;: 1P1 errors ,or%at i$cludes Q: errors APA3 )e'ere$ces7)e'ere$ce Pa*e Co$'or% to 1P1 ,or%at I$clude 1;3 1P1 errors I$clude !;: 1P1 errors I$clude Q: 1P1 errors "o $ot co$'or% to 1P1 'or%at 4riting &tyle @0ra%%ar. spelli$*. pu$ctuatio$. la$*ua*eB -o*ical. or*a$i5ed. 3ithout errors -o*ical. or*a$i5ed %i$or errors @R5B -acks lo*ic7or*a$i5atio$ % %aGor spelli$*7*ra%%ar7errors @Q5B -acks lo*ic 7 or*a$i5atio$ AND %aGor spelli$* 7 *ra%%ar 7 errors @Q5B

Points
1 3 3 3 1 1 1 0 0 0

)aculty Comments

Points A1arded

3 2 1 0

! 3 2 1 0

3 2 1 0

Co%%e$ts: